How many inspection deficiencies does PALAZZO POST ACUTE have?

PALAZZO POST ACUTE has 48 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at PALAZZO POST ACUTE?

PALAZZO POST ACUTE has a four-star staffing rating from CMS with 0.32 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is PALAZZO POST ACUTE located?

PALAZZO POST ACUTE is located in LOS ANGELES, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does PALAZZO POST ACUTE have?

PALAZZO POST ACUTE has 99 certified beds.

Who owns PALAZZO POST ACUTE?

PALAZZO POST ACUTE is a for profit - limited liability company facility and is part of the SERRANO GROUP chain.

What questions should families ask when visiting PALAZZO POST ACUTE?

Families visiting PALAZZO POST ACUTE should ask about what corrective actions were taken after fines. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does PALAZZO POST ACUTE compare to other nursing homes?

PALAZZO POST ACUTE has a 3-star overall rating, which is average compared to other nursing homes in CA. Consider visiting multiple facilities before making a decision.

PALAZZO POST ACUTE

Name: PALAZZO POST ACUTE
Address: 5400 FOUNTAIN AVE, LOS ANGELES, CA, 90029, US
Telephone: (323) 461-4301
Rating: 3.0

5400 FOUNTAIN AVE, LOS ANGELES, CA 90029 · (323) 461-4301

For profit - Limited Liability company 99 Beds SERRANO GROUP Data: November 2025

Trust Grade

23/100

#646 of 1155 in CA

Share this report:

PALAZZO POST ACUTE nursing home in LOS ANGELES, CA - Photo 1 of 5

PALAZZO POST ACUTE nursing home in LOS ANGELES, CA - Photo 2 of 5

Photo by Palazzo Post Acute

PALAZZO POST ACUTE nursing home in LOS ANGELES, CA - Photo 3 of 5

Photo by Palazzo Post Acute

PALAZZO POST ACUTE nursing home in LOS ANGELES, CA - Photo 4 of 5

Photo by Palazzo Post Acute

PALAZZO POST ACUTE nursing home in LOS ANGELES, CA - Photo 5 of 5

1 / 5 photos

Last Inspection: June 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

Palazzo Post Acute has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #646 out of 1155 facilities in California places it in the bottom half, and #128 out of 369 in Los Angeles County means only a few local options are better. The facility's trend is improving, showing a reduction in issues from 16 in 2024 to 13 in 2025. Staffing is a strength with a 4/5 rating and a low turnover of 26%, which is better than the state average. However, the facility has concerning fines totaling $101,222, which is higher than 91% of facilities in California, and it has less RN coverage than 84% of state facilities. Specific incidents include the failure to properly assess and document the care for a resident with an arterial ulcer, which could have severe implications, and a lack of supervision for a high fall-risk resident, resulting in a hip fracture. While the staffing levels are commendable, these incidents highlight critical areas needing improvement.

Trust Score: F
In California: #646/1155
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 26% annual turnover. Excellent stability, 22 points below California's 48% average. Staff who stay learn residents' needs.
Penalties: $101,222 in fines. Higher than 52% of California facilities. Some compliance issues.
Skilled Nurses: Each resident gets only 18 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 48 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★☆☆

3.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★★★★

5.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 16 issues

2025: 13 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
5-Star Quality Measures · Strong clinical quality outcomes
Low Staff Turnover (26%) · Staff stability means consistent care
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover is low (26%)
22 points below California average of 48%

Facility shows strength in staffing levels, quality measures, staff retention, fire safety.

The Bad

3-Star Overall Rating

Near California average (3.1)

Meets federal standards, typical of most facilities

Federal Fines: $101,222

Well above median ($33,413)

Significant penalties indicating serious issues

Chain: SERRANO GROUP

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 48 deficiencies on record

2 actual harm

Sept 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to protect one of three sampled residents (Resident 1) from physical abuse (any intentional act causing injury or trauma to another person by way of bodily contact) by failing to: -Ensure Certified Nursing Assistant 2 (CNA2) notified Registered Nurse 2 (RN2) that Resident 1 was agitated (to be visibly worried, upset, or restless, often showing this feeling through your movements or voice, like fidgeting or speaking in a tense way) when CNA1 did not allow Resident 1 to go smoke on 9/9/2025 at approximately 1AM. -Ensure Resident 2 did not hit Resident 1 who was blind on the left jaw (the lower part of the face below the mouth) on 9/9/2025 at 1AM. On 9/9/2025 at approximately 1AM, Resident 1 wanted to go smoke and CNA2 told Resident 1 to sit down. Resident 1 became agitated Resident 2 thought Resident 1would hit CNA2 and Resident 2 hit Resident 1 on Resident 1's left jaw. As a result, on 9/9/2025 at 1AM Resident 2 hit Resident 1 on the jaw causing Resident 1 to experience pain in the jaw and required an x-ray (medical imaging that uses radiation to take pictures of the inside of your body). Findings: 1.During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 7/26/2025 and readmitted Resident 1 on 8/26/2025 with diagnoses of lack of coordination, blindness of both eyes, schizophrenia (a mental illness that is characterized by disturbances in thought), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 1's History and Physical (H&P), dated 7/26/2025, the H&P indicated Resident 1 had no capacity (ability) for decision-making. The H&P indicated Resident 1 had a history of nicotine dependence (your brain and body rely on nicotine from tobacco or vaping products to feel normal and avoid withdrawal). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/2/2025, the MDS indicated Resident 1 had the ability to make himself (Resident 1) understood, and had the ability to understand others. During a review of Resident 1's Care Plan Report dated 8/12/2025, the Care Plan Report indicated the CNAs (in general) would monitor Resident1 for unsafe smoking practices. The Care Plan Report indicated the CNAs (in general) would notify the charge nurse immediately if it was suspected Resident 1 violated the facility's smoking policy. During a review of Resident 1's Progress Note dated 9/9/2025 at 1 AM, the Progress Note indicated Resident 1 became agitated and Resident 2 hit Resident 1 because Resident 2 believed Resident 1 was going to hit the sitter (CNA2). The Progress Note indicated Resident 2's hand landed on Resident 1's jaw. The Progress Note indicated the facility staff (unidentified) separated Resident 1 and Resident 2. During a review of Resident 1's Progress Note, dated 9/9/2025 at 2:59 AM, the Progress Note indicated Resident 1 became agitated around 1 to 1:15 AM on 9/9/2025 and stood up from the bed. The Progress Note indicated the sitter (CNA2) approached Resident 1 and tried to calm Resident 1 down. The Progress Note indicated Resident 2 moved from his bed to his wheelchair and swung his hand and hit Resident 1 on the jaw. The Progress note indicated a Registered Nurse (RN2) and Charge Nurse (LVN2) separated Resident 1 and Resident 2 with the help of the sitter (CNA2). The Progress Note indicated Resident 2 was later moved (unknown time) to another room. The Progress Note indicated Resident 1 wanted to smoke and the RN (RN2) explained to Resident 1 the facility's designated smoking times. During a review of Resident 1's Radiology (the medical specialty that uses imaging techniques, such as X-rays) Results Report, dated 9/9/2025 at 2:15 PM, indicated the reason for the study was jaw pain and the results of the x-ray was no fracture (broken bone). During a review of Resident 1's Progress Note, dated 9/12/2025 at 3:57 PM, the Progress Note indicated the Interdisciplinary Team (IDT - group of people from different professions who work together by sharing knowledge and methods to solve a complex problem) met to discuss what happened on 9/9/2025 when Resident 2 hit Resident 1. The Progress Note indicated Resident 1 wanted to go to the smoking patio around 1 AM (date not indicated) and the sitter told Resident 1 it was not time for smoking. The Progress Note indicated Resident 2 shouted at Resident 1, kneeled on his (Resident 2) wheelchair, wheeled himself (Resident 2) toward Resident 1 and struck (hit) him (Resident 1) on the left jaw with his (Resident 2) right hand. The Progress Note indicated Resident 2 believed Resident 1 had struck the sitter and that Resident 2 felt he had a sense of duty to intervene (step in) in defense of the sitter because he (Resident 2) believed a man (in general) should hit a woman (in general). 2.During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 7/2/2025 and readmitted Resident 2 on 7/29/2025 with diagnoses of type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), blindness in the left eye, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 2's H&P dated 7/3/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had the ability to make himself (Resident 2) understood and had the ability to understand others. 3.During a revied of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 6/12/2025, and readmitted Resident 3 on 8/31/2025 with diagnoses of unsteadiness on feet, and displaced intertrochanteric fracture of right femur (a severe break in the upper part of your right thigh bone that caused the broken pieces to shift out of their correct position). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had the ability to make himself (Resident 3) understood and usually had the ability to understand others. During a review of Resident 3's H&P, dated 7/29/2025, the H&P indicated Resident 3 did not have the capacity to understand and make decision. During an interview on 9/16/2025 at 10:53 AM with Resident 1 in Resident 1's room, Resident 1 stated Resident 2 hit him on the face last week (exact date not known). Resident 1 stated Resident 2 told him to shut up and stated he (Resident 1) did not know why Resident 2 hit him (Resident 1). Resident 1 stated he (Resident 2) just hit me. Resident 1 stated he (Resident 1) was blind and knew it was Resident 2 who hit him because he (Resident 1) recognized Resident 2's voice. Resident 1 stated he (Resident1) was angry at Resident 2 for hitting him (Resident 1). During an interview on 9/16/2025 at 11:42 AM with Resident 2 in Resident 2's room, Resident 2 stated he (Resident 2) heard the CNA (CNA, unidentified) told Resident 1 to sit down because Resident 1 was going to fall. Resident 2 stated he (Resident 2) saw Resident 1 get up and the CNA (unidentified female) stood in front of Resident 1. Resident 2 stated he (Resident 2) saw Resident 1 make threats and pushed the CNA (unidentified female). Resident 2 stated he (Resident 2) saw Resident 1 make a fist to hit the CNA (unidentified female) so he (Resident 2) got on his wheelchair by placing his knees on the seat of the wheelchair facing the back of the wheelchair and wheeled himself backwards in the wheelchair toward Resident 1. Resident 2 stated he (Resident 2) hit Resident 1 because I had to hit him (Resident 1). Resident 2 stated he (Resident 2) deliberately hit Resident 1 because his (Resident 1) behavior warranted him (Resident 2) to hit Resident 1. Resident 2 stated the incident began when Resident 1 wanted to smoke early in the morning (unknown date). Resident 2 stated he hit Resident 1 because he (Resident 2) was brought up to protect women referring to the female CNA (undentified) who was trying to prevent Resident 1 from falling. During an interview on 9/16/2025 at 12:04 PM with LVN 1, LVN 1 stated he (LVN1) received a report from the night charge nurse (LVN 2) during the morning shift change on 9/9/2025. LVN 1 stated LVN 2 reported an incident between Resident 1 and Resident 2. LVN 1 stated LVN 2 reported Resident 1 had been agitated because he (Resident 1) wanted to smoke outside of the facility's designated smoking hours. LVN 1 stated Resident 1 and Resident 2 were in a room with a sitter (CNA2) in the Resident 1 and Resident 2's room because Resident 1 and Resident 2 were at risk for a fall. During an interview on 9/16/2025 at 12:28 PM with the Director of Nursing (DON) and Director of Staff Development (DSD), the DON stated she (DON) received a call from the facility on 9/9/2025 approximately between 1:30AM and 2 AM. The DON stated she (DON) interviewed LVN 2 and RN 2 over the phone. The DON and the DSD stated the incident began when Resident 1 wanted to smoke outside of the facility's designated (officially chosen) smoking hours which were from 9 AM to 8:30 PM daily. The DON stated Resident 2 reported he (Resident 2) wanted to protect CNA 2 from Resident 1 who was agitated after CNA 2 tried to educate Resident 1 about the facility's smoking hours. The DON stated Resident 1 attempted to get up and CNA 2 positioned herself (CNA 2) to prevent Resident 1 from falling. During an interview on 9/16/2025 at 12:56 PM with CNA 2, CNA 2 stated Resident 1 wanted to smoke in the early morning of 9/9/2025 and she (CNA2) tried to get out of bed. CNA 2 stated Resident 1 was blind and at risk for falling so CNA 2 tried to keep Resident 1 from getting up. CNA 2 stated Resident 2 thought Resident 1 was going to hit her (CNA 2). CNA 2 stated Resident 2 got up, and CNA 2 called for help. CNA 2 stated Resident 2 then hit Resident 1. During an interview on 9/16/2025 at 1:24 PM with Resident 3, Resident 3 stated he (Resident 3) was awake on the night when Resident 2 hit Resident 1. Resident 3 stated Resident 1 had been very rough with the staff and Resident 1 had been aggressive. During an interview on 9/16/2025 at 1:35 PM with LVN 2, LVN 2 stated he (LVN2) was the Charge Nurse on the night/early morning of 9/9/2025. LVN 2 stated he (LVN2) heard a call for help and went to the room where Resident 1 and Resident 2 were located. LVN 2 stated CNA 2 tried to keep Resident 1 from falling. LVN 2 stated he (LVN2) saw Resident 2 hit Resident 1 on 9/9/2025 approximately 1 AM in the morning. During an interview on 9/16/2025 at 1:44 PM with RN 2, RN 2 stated he (RN2) heard a commotion (a sudden, noisy, and confusing burst of activity) coming from Resident 1 and Resident 2's room and he (RN2) went to investigate. RN 2 stated he (RN2) observed CNA 2 positioned between Resident 1 and Resident 2. RN 2 stated Resident 1 was agitated because he (Resident 1) wanted to smoke. RN 2 stated he (RN2) gave Resident 1 Tylenol (over-the-counter medicine that relieves mild to moderate pain and reduces fever) because Resident 1 complained of an aching jaw pain that was rated at 3 out of 10 (mild pain [0 means no pain and 10 means having the worst pain]). During a review of the facility's policy and procedure (P&P), titled Identifying Types of Abuse, last reviewed 1/23/2025, the P&P indicated the facility's employees were expected to identify different types of abuse that may occur against residents as part of the facility's abuse prevention strategy. The P&P indicated abuse of any kind is strictly prohibited (not allowed). The P&P indicated a type of abuse is resident to resident and includes, but not limited to hitting, slapping, biting, punching, or kicking. During a review of the facility's policy and procedure (P&P), titled Abuse Prevention Program, last reviewed 1/23/2025, the P&P indicated the facility's residents have the right to be free from abuse including mental and physical abuse. The P&P indicated the facility would protect residents from abuse by anyone including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. The P&P indicated the facility staff would require staff training/orientation for abuse prevention, identification and reporting of abuse, stress management and handling of verbal or physically aggressive resident behavior. The P&P indicated the facility would implement (put into place) measures to address factors that may lead to abusive situation including helping staff to understand how cultural, religious, and ethnic (a group of people who share a common cultural background, which can include things like their language, traditions, ancestry, religion, or way of life, often passed down through generations) can lead to misunderstandings and conflict.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to supervise two of three residents (Resident 1 and Resident 2) by failing to: -Ensure Certified Nursing Assistant 2 (CNA2) notified Registered Nurse 2 (RN2) that Resident 1 was agitated (to be visibly worried, upset, or restless, often showing this feeling through your movements or voice, like fidgeting or speaking in a tense way) when CNA1 did not allow Resident 1 to go smoke on 9/9/2025 at approximately 1AM. -Ensure Resident 2 did not hit Resident 1 who was blind on the left jaw (the lower part of the face below the mouth) on 9/9/2025 at 1AM. -Ensure Resident 1 and Resident 2 had adequate supervision to prevent Resident 2 from hitting Resident 1 on his jaw. On 9/9/2025 at approximately 1AM, Resident 1 wanted to go smoke and CNA2 told Resident 1 to sit down. Resident 1 became agitated Resident 2 thought Resident 1would hit CNA2 and Resident 2 hit Resident 1 on Resident 1's left jaw. As a result, on 9/9/2025 at 1AM Resident 2 hit Resident 1 on the jaw causing Resident 1 to experience pain in the jaw and required an x-ray (medical imaging that uses radiation to take pictures of the inside of your body). Findings: 1.During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 7/26/2025 and readmitted Resident 1 on 8/26/2025 with diagnoses of lack of coordination, blindness of both eyes, schizophrenia (a mental illness that is characterized by disturbances in thought), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 1's History and Physical (H&P), dated 7/26/2025, the H&P indicated Resident 1 had no capacity (ability) for decision-making. The H&P indicated Resident 1 had a history of nicotine dependence (your brain and body rely on nicotine from tobacco or vaping products to feel normal and avoid withdrawal). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/2/2025, the MDS indicated Resident 1 had the ability to make himself (Resident 1) understood, and had the ability to understand others. During a review of Resident 1's Care Plan Report dated 8/12/2025, the Care Plan Report indicated the CNAs (in general) would monitor Resident1 for unsafe smoking practices. The Care Plan Report indicated the CNAs (in general) would notify the charge nurse immediately if it was suspected Resident 1 violated the facility's smoking policy. During a review of Resident 1's Progress Note dated 9/9/2025 at 1 AM, the Progress Note indicated Resident 1 became agitated and Resident 2 hit Resident 1 because Resident 2 believed Resident 1 was going to hit the sitter (CNA2). The Progress Note indicated Resident 2's hand landed on Resident 1's jaw. The Progress Note indicated the facility staff (unidentified) separated Resident 1 and Resident 2. During a review of Resident 1's Progress Note, dated 9/9/2025 at 2:59 AM, the Progress Note indicated Resident 1 became agitated around 1 to 1:15 AM on 9/9/2025 and stood up from the bed. The Progress Note indicated the sitter (CNA2) approached Resident 1 and tried to calm Resident 1 down. The Progress Note indicated Resident 2 moved from his bed to his wheelchair and swung his hand and hit Resident 1 on the jaw. The Progress note indicated a Registered Nurse (RN2) and Charge Nurse (LVN2) separated Resident 1 and Resident 2 with the help of the sitter (CNA2). The Progress Note indicated Resident 2 was later moved (unknown time) to another room. The Progress Note indicated Resident 1 wanted to smoke and the RN (RN2) explained to Resident 1 the facility's designated smoking times. During a review of Resident 1's Radiology (the medical specialty that uses imaging techniques, such as X-rays) Results Report, dated 9/9/2025 at 2:15 PM, indicated the reason for the study was jaw pain and the results of the x-ray was no fracture (broken bone). During a review of Resident 1's Progress Note, dated 9/12/2025 at 3:57 PM, the Progress Note indicated the Interdisciplinary Team (IDT - group of people from different professions who work together by sharing knowledge and methods to solve a complex problem) met to discuss what happened on 9/9/2025 when Resident 2 hit Resident 1. The Progress Note indicated Resident 1 wanted to go to the smoking patio around 1 AM (date not indicated) and the sitter told Resident 1 it was not time for smoking. The Progress Note indicated Resident 2 shouted at Resident 1, kneeled on his (Resident 2) wheelchair, wheeled himself (Resident 2) toward Resident 1 and struck (hit) him (Resident 1) on the left jaw with his (Resident 2) right hand. The Progress Note indicated Resident 2 believed Resident 1 had struck the sitter and that Resident 2 felt he had a sense of duty to intervene (step in) in defense of the sitter because he (Resident 2) believed a man (in general) should hit a woman (in general). 2.During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 7/2/2025 and readmitted Resident 2 on 7/29/2025 with diagnoses of type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), blindness in the left eye, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 2's H&P dated 7/3/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had the ability to make himself (Resident 2) understood and had the ability to understand others. 3.During a revied of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 6/12/2025, and readmitted Resident 3 on 8/31/2025 with diagnoses of unsteadiness on feet, and displaced intertrochanteric fracture of right femur (a severe break in the upper part of your right thigh bone that caused the broken pieces to shift out of their correct position). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had the ability to make himself (Resident 3) understood and usually had the ability to understand others. During a review of Resident 3's H&P, dated 7/29/2025, the H&P indicated Resident 3 did not have the capacity to understand and make decision. During an interview on 9/16/2025 at 10:53 AM with Resident 1 in Resident 1's room, Resident 1 stated Resident 2 hit him on the face last week (exact date not known). Resident 1 stated Resident 2 told him to shut up and stated he (Resident 1) did not know why Resident 2 hit him (Resident 1). Resident 1 stated he (Resident 2) just hit me. Resident 1 stated he (Resident 1) was blind and knew it was Resident 2 who hit him because he (Resident 1) recognized Resident 2's voice. Resident 1 stated he (Resident1) was angry at Resident 2 for hitting him (Resident 1). During an interview on 9/16/2025 at 11:42 AM with Resident 2 in Resident 2's room, Resident 2 stated he (Resident 2) heard the CNA (CNA, unidentified) told Resident 1 to sit down because Resident 1 was going to fall. Resident 2 stated he (Resident 2) saw Resident 1 get up and the CNA (unidentified female) stood in front of Resident 1. Resident 2 stated he (Resident 2) saw Resident 1 make threats and pushed the CNA (unidentified female). Resident 2 stated he (Resident 2) saw Resident 1 make a fist to hit the CNA (unidentified female) so he (Resident 2) got on his wheelchair by placing his knees on the seat of the wheelchair facing the back of the wheelchair and wheeled himself backwards in the wheelchair toward Resident 1. Resident 2 stated he (Resident 2) hit Resident 1 because I had to hit him (Resident 1). Resident 2 stated he (Resident 2) deliberately hit Resident 1 because his (Resident 1) behavior warranted him (Resident 2) to hit Resident 1. Resident 2 stated the incident began when Resident 1 wanted to smoke early in the morning (unknown date). Resident 2 stated he hit Resident 1 because he (Resident 2) was brought up to protect women referring to the female CNA (undentified) who was trying to prevent Resident 1 from falling. During an interview on 9/16/2025 at 12:04 PM with LVN 1, LVN 1 stated he (LVN1) received a report from the night charge nurse (LVN 2) during the morning shift change on 9/9/2025. LVN 1 stated LVN 2 reported an incident between Resident 1 and Resident 2. LVN 1 stated LVN 2 reported Resident 1 had been agitated because he (Resident 1) wanted to smoke outside of the facility's designated smoking hours. LVN 1 stated Resident 1 and Resident 2 were in a room with a sitter (CNA2) in the Resident 1 and Resident 2's room because Resident 1 and Resident 2 were at risk for a fall. During an interview on 9/16/2025 at 12:28 PM with the Director of Nursing (DON) and Director of Staff Development (DSD), the DON stated she (DON) received a call from the facility on 9/9/2025 approximately between 1:30AM and 2 AM. The DON stated she (DON) interviewed LVN 2 and RN 2 over the phone. The DON and the DSD stated the incident began when Resident 1 wanted to smoke outside of the facility's designated (officially chosen) smoking hours which were from 9 AM to 8:30 PM daily. The DON stated Resident 2 reported he (Resident 2) wanted to protect CNA 2 from Resident 1 who was agitated after CNA 2 tried to educate Resident 1 about the facility's smoking hours. The DON stated Resident 1 attempted to get up and CNA 2 positioned herself (CNA 2) to prevent Resident 1 from falling. During an interview on 9/16/2025 at 12:56 PM with CNA 2, CNA 2 stated Resident 1 wanted to smoke in the early morning of 9/9/2025 and she (CNA2) tried to get out of bed. CNA 2 stated Resident 1 was blind and at risk for falling so CNA 2 tried to keep Resident 1 from getting up. CNA 2 stated Resident 2 thought Resident 1 was going to hit her (CNA 2). CNA 2 stated Resident 2 got up, and CNA 2 called for help. CNA 2 stated Resident 2 then hit Resident 1. During an interview on 9/16/2025 at 1:24 PM with Resident 3, Resident 3 stated he (Resident 3) was awake on the night when Resident 2 hit Resident 1. Resident 3 stated Resident 1 had been very rough with the staff and Resident 1 had been aggressive. During an interview on 9/16/2025 at 1:35 PM with LVN 2, LVN 2 stated he (LVN2) was the Charge Nurse on the night/early morning of 9/9/2025. LVN 2 stated he (LVN2) heard a call for help and went to the room where Resident 1 and Resident 2 were located. LVN 2 stated CNA 2 tried to keep Resident 1 from falling. LVN 2 stated he (LVN2) saw Resident 2 hit Resident 1 on 9/9/2025 approximately 1 AM in the morning. During an interview on 9/16/2025 at 1:44 PM with RN 2, RN 2 stated he (RN2) heard a commotion (a sudden, noisy, and confusing burst of activity) coming from Resident 1 and Resident 2's room and he (RN2) went to investigate. RN 2 stated he (RN2) observed CNA 2 positioned between Resident 1 and Resident 2. RN 2 stated Resident 1 was agitated because he (Resident 1) wanted to smoke. RN 2 stated he (RN2) gave Resident 1 Tylenol (over-the-counter medicine that relieves mild to moderate pain and reduces fever) because Resident 1 complained of an aching jaw pain that was rated at 3 out of 10 (mild pain [0 means no pain and 10 means having the worst pain]). During a review of the facility's policy and procedure (P&P), titled Identifying Types of Abuse, last reviewed 1/23/2025, the P&P indicated the facility's employees were expected to identify different types of abuse that may occur against residents as part of the facility's abuse prevention strategy. The P&P indicated abuse of any kind is strictly prohibited (not allowed). The P&P indicated a type of abuse is resident to resident and includes, but not limited to hitting, slapping, biting, punching, or kicking. During a review of the facility's policy and procedure (P&P), titled Abuse Prevention Program, last reviewed 1/23/2025, the P&P indicated the facility's residents have the right to be free from abuse including mental and physical abuse. The P&P indicated the facility would protect residents from abuse by anyone including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. The P&P indicated the facility staff would require staff training/orientation for abuse prevention, identification and reporting of abuse, stress management and handling of verbal or physically aggressive resident behavior. The P&P indicated the facility would implement (put into place) measures to address factors that may lead to abusive situation including helping staff to understand how cultural, religious, and ethnic (a group of people who share a common cultural background, which can include things like their language, traditions, ancestry, religion, or way of life, often passed down through generations) can lead to misunderstandings and conflict.

Jun 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement the care plan interventions to prevent falls for one of three sampled residents (Resident 1). For Resident 1, the facility failed to anticipate Resident 1 ' s needs during transfer from the toilet to the wheelchair on 2/19/25. This deficient practice resulted in Resident 1 sliding off the wheelchair and fell to the floor. Resident 1 had the potential to sustain injury because of the fall. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 1/9/25 and re-admitted on [DATE] with diagnoses including abnormalities of gait and mobility, lack of coordination and need for assistance with personal care. During a review of Resident 1 ' s Care Plan initiated on 1/9/25 indicated Resident 1 was at risk for falls related to history of falling, impaired gait/balance. The Care Plan goal indicated Resident 1 will minimize risk of falls or injuries for 90 days. The care plan interventions included adapt environment to meet the resident ' s safety needs, anticipate and meet the residents needs and assist will all transfers or ambulation. During a review of the Minimum Data Set (MDS, a resident assessment tool dated) 1/16/25 indicated Resident 1 was cognitively intact. Resident 1 needed substantial assistance (helper does more than half the effort) with sit to stand, chair/bed-to-chair transfer and toilet transfer. During a review of the Fall Risk assessment dated [DATE] at 7:40 a.m., indicated Resident 1 was wheelchair bound and needed assistance with elimination. The Assessment indicated Resident 1 was high risk for fall. During a review of the Change in Condition dated 2/19/25 at 4 a.m., indicated Resident 1 fell from the wheelchair while coming out of the bathroom on 2/19/25. Resident 1 stated the certified nursing assistant (CNA) did not handle the wheelchair properly and was rough. The notes indicated Resident 1 had no injury. The primary physician was notified and gave order for X-ray of the left shoulder, bilateral elbows and left hip. During a review of the x-ray result dated 2/20/25 at 3:32 p.m., indicated Resident 1 had no injuries. During a review of the Interdisciplinary Risk Management Review Note dated 2/21/25 at 3:36 p.m., indicated Resident 1 had a witnessed fall on 2/19/25. The Note indicated Resident 1 was not properly positioned in the wheelchair .while being pushed in wheelchair which cause her (Resident 1) to slide off and land on the floor. During a concurrent interview on 6/17/25 at 10:09 a.m., Resident 1 ' s fall incident dated 2/19/25 was reviewed with licensed vocational nurse (LVN 1). LVN 1 stated on 2/19/25, Resident 1 was in the bathroom and was assisted from the toilet to the wheelchair by the CNA. LVN 1 stated Resident 1 was not properly positioned in the wheelchair and when CNA pushed the wheelchair out of the bathroom, Resident 1 slide off the wheelchair and fell to the floor. LVN 1 stated Resident 1 ' s primary physician was notified and gave order for x-ray of the shoulder, elbow and hips. LVN 1 stated Resident 1 should be seated properly in the wheelchair .with her back all the way to the back of the wheelchair. LVN 1 stated Resident 1 had no injuries. During an interview on 6/17/25 at 12:10 p.m., the director of nursing (DON) stated on 2/19/25, Resident 1 was transferred from the toilet to the wheelchair. Resident 1 was sitting close to the edge of the seat of the wheelchair, slid off and fell on the floor. DON stated the CNA should have fixed how Resident 1 was sitting in the wheelchair. During a review of the facility's policy and procedures titled Safety and Supervision of Residents reviewed on 1/23/25, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. The Policy indicated the individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The same Policy indicated implementing interventions to reduce accident risks and hazards included providing training as necessary and ensuring that interventions are implemented. During a review of the facility's P&P titled Care Plans, Comprehensive Person-Centered reviewed on 1/23/25, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident.

Jun 2025 9 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 9) who did not have the capacity to understand and make decisions had a legal representative to assist in making medical decisions. This failure violated Resident 9's right to make an informed decision (choice that individuals make once they have all the information related to the decision topic) in the resident' care. Findings: During a review of Resident 9's admission Record, the admission Record indicated the facility readmitted Resident 9 on 5/10/2018, with diagnoses that included major depressive disorder (persistent feelings of sadness, low mood, and loss of interest in activities that were once pleasurable), schizophrenia (a mental illness that is characterized by disturbances in thought), age-related incipient cataract (in its early stages, where the lens of the eye is starting to become cloudy but vision is not yet significantly affected), and anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life). During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool) dated 4/21/2025, the MDS indicated the resident was severely cognitively (anything related to thinking, learning, and understanding) impaired for decision making. During a review of Resident 9's History and Physical (H&P), dated 6/17/2024, the H&P indicated Resident 9 did not have the capacity to understand and make decisions. During a review of Resident 9's Facility Consent Form for psychotropic medication (drugs that affect the mind and brain), dated 11/1/2024, the Consent Form indicated, Verbal consent obtained from resident with two witnessed signatures on resident/representative signature line, nurse signature and physician signature. During a review of Resident 9's Multidisciplinary Care Conference, dated 4/23/2025, the Multidisciplinary Care Conference indicated, Interdisciplinary Team (IDT, a group of diverse health care professionals from different fields) held with resident at bedside for a careplan meeting to discuss current Plan of Care (POC). Nursing discussed current medication orders. Verbalized understanding, no concerns at this time. Social Services documented resident (Resident 9) has periods of confusion. During a review of Resident 9's Advance Directive (a written statements of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) Acknowledgment, dated 6/4/2025, the Advance Directive Acknowledgment indicated Resident 9 initialed and signed the document with two witnesses. During an interview on 6/5/2025 at 11:21 AM with Resident 9, Resident 9 stated, I signed a document yesterday with the Social Services Assistant (SSA) and wrote a D because I am unable to sign. I am able to move my fingers but unable to see for quite some time. I have limited vision - I can only see shadows. During an interview on 6/5/2025 at 11:41 AM with SSA, the SSA stated on 6/4/2025 Resident 9 signed the Advance Health Care Directive. During an interview on 6/5/2025 at 12:13 PM with the Director of Nursing (DON), the DON stated Resident had limited visual capacity and needed to have a Witness to sign. During a concurrent interview and record review on 6/5/2025 at 12:20 PM with the DON, Resident 9's H&P dated 6/17/2024 and MDS dated [DATE] were reviewed. The DON indicated the H&P indicated Resident 9 Does not have the capacity to understand and make decisions. The DON stated the MDS indicated Resident 9 was severely cognitively impaired for decision making. The DON stated Resident 9 did not have the capacity to make decisions and sign an Advance Health Care Directive and consents. During an interview on 6/5/2025 at 12:27 PM with SSA, the SSA stated Before a resident signs a document, they (residents in general) need to have the capacity to make decisions. The Resident (Resident 9) has moments of confusion. During an interview on 6/5/2025 at 12:33 PM with SSA, the SSA stated I don't know the advance directives policy. During an interview on 6/5/2025 at 2:30 PM with Medical Director (MD), the MD stated When a resident has cognitive decline, a bioethics (group of physicians, nurses, social workers, other staff members to help patients, families, doctors and other health care provides when they face difficult ethical decisions) meeting needs to be done with the next step being filing for a conservator (legal guarding). During IDT (Intradisciplinary Team, a group of diverse health care professionals from different fields meetings), involve psychiatry (is the branch of medicine that focuses on the prevention, diagnosis, and treatment of mental, behavioral, and emotional disorders). During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated December 2021, the P&P indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: appoint a legal representative of his or her choice, in accordance with state law.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update the care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) for one of five sampled residents (Resident 47) related to the risk for falls after Resident 47 had a fall on 12/26/2024. This failure had the potential for Resident 47 to receive inadequate care. Findings: During a review of Resident 47's admission Record, the admission Record indicated the facility admitted the resident on 8/3/2023 with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movements), encephalopathy (a group of conditions that cause brain dysfunction), unsteadiness on feet (difficulty maintaining balance while walking or standing), lack of coordination (an inability to control and synchronize movements smoothly and efficiently), and a history of falling. During a review of Resident 47's Minimum Data Set (MDS, a resident assessment tool) dated 11/10/2024, the MDS indicated the resident was cognitively intact (had the ability to think, understand, and reason). The MDS indicated Resident 47 required set up or clean up assistance for eating and oral hygiene. The MDS indicated Resident 47 required supervision or touching assistance for toileting hygiene, upper body dressing, or personal hygiene. The MDS indicated Resident 47 required partial/moderate assistance for showering/bathing himself, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 47 did not have any falls since his admission to the facility. During a review of Resident 47's eInteract Change in Condition Evaluation dated 12/26/2024 at 1:48 PM, the eInteract Change in Condition Evaluation indicated the resident had a fall. The eInteract Change in Condition Evaluation indicated Resident 47 was found on the floor sitting and holding onto his walker (a type of mobility aid that offers stability and support while walking). The eInteract Change in Condition Evaluation indicated Resident 47 was assisted back to bed. The eInteract Change in Condition Evaluation indicated Resident 47 denied hitting his head or his bottom. The eInteract Change in Condition Evaluation indicated Resident 47 was found without redness or bruising upon assessment. The eInteract Change in Condition Evaluation further indicated Resident 47's physician was notified and ordered for Resident 47 to have an x-ray (a medical test that takes pictures of bones and soft tissues). During a review of Resident 47's Care Plan Report dated 5/20/2025, the Care Plan Report indicated the resident was at risk for falls related to unsteady and shuffling gait (walking without lifting your feet completely off the ground), a history of falls, and a history of being non-compliant (not acting in accordance with a wish or command) with the use of his front wheel walker when ambulating (walking). The Care Plan Report indicated a goal to minimize Resident 47's risk for falls and injuries. The Care Plan Report indicated interventions that were last revised on 10/9/2023. The Care Plan Report did not indicate any intervention revisions or updates after Resident 47's fall on 12/26/2024. During a concurrent interview and record review on 6/5/2025 at 11:18 AM with the MDS Coordinator (MDSC), Resident 47's eInteract Change in Condition Evaluation dated 12/26/2024 and Care Plan Report dated 5/20/2025 were reviewed. The MDSC stated Resident 47 had a fall on 12/26/2024. The MDSC stated resident care plans were reviewed and updated after every fall. The MDSC stated after a resident (in general) had a fall a short-term care plan was developed and the care plan was updated with additional interventions for the at risk for falls. The MDSC stated Resident 47's at risk for falls care plan was not updated after the resident fell on [DATE]. The MDSC stated Resident 47's at risk for falls care plan should have been updated after his fall on 12/26/2024. The MDSC stated that it was important for Resident 47's at risk for falls care plan to be revised and updated after each fall so the nursing staff were aware of the interventions they were to provide to the resident. During a concurrent interview and record review on 6/5/2025 at 3:10 PM with the Director of Nursing (DON), Resident 47's eInteract Change in Condition Evaluation dated 12/26/2024 and Care Plan Report dated 5/20/2025 were reviewed. The DON stated Resident 47 had a fall on 12/26/2024. The DON stated Resident 47's at risk for falls care plan was not updated after he (Resident 47) fell on [DATE]. The DON stated Resident 47's at risk for falls care plan should have been updated and revised to include additional interventions to prevent the resident from falling again. The DON stated a resident's care plan (in general) was indicative of the kind of care the resident was to receive. The DON stated if care plans were not updated after a fall there was a potential for the resident to not receive appropriate care because the nursing staff would not be aware of the care the resident was to receive. During a review of the facility's Policy & Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered dated 1/23/2025, the P&P indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The interdisciplinary team reviews and updates the care plan: when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and record review the facility failed to ensure to provide effective oral hygiene care for one of five sampled residents (Resident 39). This failure resulted in Resident 39 having a tan substance on her teeth, dry lips, and a substance on her reddened, tongue. Findings: During a review of Resident 39's admission Record, the admission Record indicated the facility admitted the resident on 10/19/2022 with diagnoses that included dysphagia (difficulty swallowing), gastrostomy (g-tube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and malnutrition (lack of proper nutrition). During a review of the Resident 39's Care Plan Report dated 1/3/2025, the Care Plan Report indicated the resident was at risk for decline in range of motion (ROM, the full movement potential of a joint), and required assistance with oral care. The Care Plan Report indicated the nursing interventions were to provide oral care three times a day. During a review of Resident 39's Minimum Data Set (MDS - a resident assessment tool) dated 3/27/2025, the MDS indicated Resident 39 had poor short and long-term memory problems. The MDS indicated Resident 39 had severely impaired cognitive (ability to think and process information) skills. The MDS indicated Resident 39 was dependent for oral and toileting hygiene, and for showering and upper and lower dressing. During an observation on 6/2/2025 at 10:40 AM in Resident 39's room, Resident 39 was sleeping in bed, two side rails (adjustable metal or rigid plastic bars that attach to the bed) were up, the call light (a device used by a patient to signal his or her need for assistance) was within reach. Resident 39 had a gastrostomy tube, and the head of the bed was raised to 30 degrees. Resident 39 had a tan colored substance on her teeth, dry lips, and a substance on her tongue. Resident 39's tongue appeared reddened and swollen. During an interview on 6/4/2025 at 1:20 PM with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 39 was total care and could not do the task herself. CNA 1 stated she (CNA 1) performed oral care on Resident 39 early in the morning using the mouth swab. CNA 1 stated she (CNA 1) performed oral care for Resident 39 twice a day. CNA 1 stated Resident 1's mouth looked that way (had a tan colored substance on her teeth, dry lips, and a substance on her tongue. Resident 39's tongue appeared reddened and swollen) for a while. During an observation and interview on 6/4/2025 at 1:30 PM with Registered Nurse (RN) 1 in Resident 39's room, RN 1 stated Resident 39's mouth looked bad. RN 1 stated if he (RN 1) had a loved who had a mouth appeared as Resident 39's, he (RN 1) would go to the nurse and see what interventions were being done, ask if the doctor was aware. RN 1 would not confirm or deny that Resident 39's mouth did not get consistent oral care. RN1 stated he (RN 1) would do a change of condition (a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains), inform Resident 39's doctor, and place a dental consult. During a review of Resident 39's eINTERACT Change in Condition Evaluation Dated 6/4/25, the eINTERACT Change in Condition Evaluation indicated the CNA notified the Licensed Nurse regarding possible tongue swelling. The eINTERACT Change in Condition Evaluation indicated the nurse tried to do an assessment but was unsuccessful due to Resident 39 not sticking out her tongue and showing discomfort. The eINTERACT Change in Condition Evaluation indicated the doctor was made aware with new orders for a dental follow up and laboratory tests. During an interview on 6/4/25 at 2:32 PM with the Registered Dental Hygienist (RDH), the RDH stated she (RDH) saw Resident 39 in January 2025 and on 5/30/2025 and performed a dental cleaning. The RDH stated Resident 39 was not cooperative. The RDH stated she (RDH) was able to get the plaque off but not the calculus (a hardened form of plaque that forms on teeth when plaque isn't effectively removed with brushing and flossing). The RDH stated she (RDH) did not see that Resident 39's tongue appeared reddened, scaly, or swollen. The RDH stated she (RDH) did not use a bite stick only used hand instruments to retract and no injury was noted. The RDH stated it was hard to say if Resident 39 received consistent oral care. The RDH was informed that Resident 39 does not have anything by mouth. The RDH stated she (RDH) did not give any recommendations to the nursing staff after the examination. During an observation on 6/5/2025 at 8:55 AM in Resident 39's room, Resident 39's mouth showed moisturized lips, teeth had less substance on them, and the resident's tongue appeared less swollen and dry. During an interview on 6/5/2025 at 9:17 AM with the Director of Nursing (DON), the DON stated all residents, especially the residents with g-tubes, should receive oral care every day. The DON stated if her family member's mouth looked like what Resident 39's mouth looked on 6/4/2025 which was dry lips, teeth with a substance on them, it would not be acceptable. The DON stated the risk to Resident 39 would be infection. During a review of Resident 39's Dental Progress Notes dated 6/5/25, the Dental Progress Note indicated the resident's tongue was checked and the resident was sleeping with her mouth opened. The Dental Progress Note indicated Resident 39's mouth and tongue were extremely dry, her togue was not swollen, and there was no abnormality of her tongue. The Dental Progress Noted indicated a recommendation to moisten Resident 39's tongue and to provide good oral hygiene. During a review of the facility's policy and procedures (P&P) titled, Mouth Care, dated 1/23/2025, indicated, that the purpose of the procedures are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth and to prevent oral infection.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure to implement safety measures for one of one sampled residents (Resident 63) by failing to: -Ensure Certified Nursing Assistants (CNA2 and CNA3) locked Resident 63's bed and the Hoyer lift (a specialized lifting device to weigh or safely transfer a patient with limited mobility) prior to placing the sling (a specialized fabric support, acts as a harness) under Resident 63 on 6/2/2025 at 10:58 AM. This failure had the potential to cause physical injury to Resident 63. Findings: During a review of Resident 63's admission Record, the admission Record indicated the facility admitted the resident on 10/3/2024 with diagnoses including hemiplegia (paralysis that affects one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction affecting right non-dominant side, other sequelae of cerebral infarction (a loss of blood flow to part of the brain, which damages brain tissues), aphasia following cerebral infarction (a language disorder that occurs when a stroke damages brain areas responsible for language processing), and history of falling. During a review of Resident 63's Care Plan dated 10/3/2024, indicated Resident 63 was at risk for falls related to impaired gait/balance and mobility. The Care Plan indicated Resident 63 had a history of falling and was taking medications that may cause falls and the goal was for Resident 63 to minimize the risk of falls or injuries. The Care Plan indicated the nursing interventions included to adapt environment to meet resident's safety needs, assist with all transfers or ambulation (walking), and Resident 63 needs a safe environment with .bed wheels locked . During a review of Resident 63's History and Physical (H&P) dated 10/4/2024, the H&P indicated Resident 63 had fluctuating capacity to understand and make medical decisions. During a review of Resident 63's Minimum Data Set (MDS, a resident assessment tool) dated 4/10/2025, the MDS indicated Resident 63 was cognitively intact (a person's thinking and reasoning abilities are functioning properly and are not significantly impaired). The MDS indicated Resident 63 required one or two staff to assist with Resident 63's activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 63's Physician Progress Note dated 5/11/2025, the Physician Progress Note indicated Resident 63 had an unsteady gait. During an observation and concurrent interview on 6/2/2025 at 10:58 AM, inside Resident 63's room, CNA2 and CNA 3 did not lock Resident 63's bed and the Hoyer lift prior to placing the sling under Resident 63. CNA 2 stated Resident 63's bed and the Hoyer lift should have been locked prior to placing the sling under Resident 63 to secure Resident 63 from falling off the bed and to prevent accidents such as fracture (break) of the arm, or leg, or an injury requiring hospitalization. CNA 3 stated Resident 63's bed and the Hoyer lift must be locked prior to placing the sling under Resident 63 to prevent from hitting Resident 63's head on the floor and bleed which requires going to the hospital immediately because of (Resident 63's) injury. During an interview on 6/2/2025 at 11:15 AM with Licensed Vocational Nurse (LVN 4), LVN 4 stated both Resident 63's bed and the Hoyer lift must be locked prior to moving Resident 63 to prevent accidents such as falls where Resident 63 may sustain injuries such as broken bones in the extremities (limbs of the body-arms and legs) and altered level of consciousness (a change in a person's awareness of themselves and their surroundings, ranging from mild confusion to a coma). LVN 4 stated Resident 63 may sustain a head bleed that may result in Resident 63 being sent to the hospital. During an interview on 6/2/2025 at 11:28 AM with Registered Nurse 1 (RN 1), RN 1 stated Resident 63's bed and the Hoyer lift must be locked to ensure the equipment was stable and not moving. RN 1 stated potential injuries Resident 63 may sustain included head concussion (brain injury caused by a bump, blow, or jolt to the head, or by a hit to the body that can result in a range of symptoms, including headache, dizziness, confusion, and memory problems), pain, discomfort, altered mental status (change in mental function that maybe as a result of illness or injuries), and neurological deficit (injury or changes to how the brain, spinal cord, and nerves work). During a review of the facility's policy and procedures titled Lifting Machine, Using a Mechanical with a revision date of 1/23/2025, indicated when preparing the environment, staff make sure lift is stable and locked.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review, the facility failed to perform a bowel and bladder assessment (a process to evaluate a person's bowel and bladder function) quarterly as indicated in the care plan for one of one sampled residents (Resident 66). This failure had the potential for Resident 66 to not receive the appropriate care for her bowel and bladder function. Findings: During a review of Resident 66's admission Record, the admission Record indicated the facility admitted the resident on 11/8/2024 with diagnoses that included congestive heart failure (CHF, a heart disorder which causes the heart to not pump blood efficiently, sometimes resulting in leg swelling), cirrhosis of the liver (a disease where healthy liver tissue is replaced by scar tissue), reduced mobility (an impairment that impacts a person's ability to move or perform tasks), and adult failure to thrive (a condition characterized by a decline in physical, cognitive (ability to understand, think, and reason), and social functioning in adults). During a review of Resident 66's Nursing Bowel and Bladder Evaluation dated 2/14/2025 at 9:37 AM, the Nursing Bowel and Bladder Evaluation indicated Resident 66 had a potential for bowel and bladder retraining (technique used to regain control over urination and bowel movements). The Nursing Bowel and Bladder Evaluation indicated Resident 66 had minor predisposing diseases, was alert and oriented, was able to make needs known, required limited assistance with mobility, had adequate vision and hearing, was frequently incontinent (having insufficient voluntary control) of bladder, and frequently incontinent of bowel. There were no Nursing Bowel and Bladder Evaluations documented after 2/14/2025. During a review of Resident 66's Minimum Data Set (MDS, a resident assessment tool) dated 5/15/2025, the MDS indicated the resident was cognitively intact (had the ability to think, understand, and reason). The MDS indicated Resident 66 required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene. The MDS indicated Resident 66 was occasionally incontinent of urine and frequently incontinent of bowel. The MDS indicated Resident 66 was not on a bowel program (a structured plan designed to help individuals achieve regular and predictable bowel movements). During a review of Resident 66's Care Plan Report dated 6/2/2025, the Care Plan Report indicated the resident was always incontinent of bowel and always incontinent of bladder. The Care Plan Report indicated Resident 66 was not a good candidate to establish an individualized toileting plan due the resident's complex medical condition. The Care Plan Report indicated a goal for Resident 66 to not develop complications from incontinence such as skin breakdown or infection. The Care Plan Report further indicated interventions that included to perform a bowel and bladder assessment on admission, quarterly, and as needed. During a concurrent interview and record review on 6/5/2025 at 9:20 AM, with Registered Nurse 1 (RN 1), Resident 66's Nursing Bowel and Bladder Evaluation dated 2/14/2025 at 9:37 AM and Care Plan Report dated 6/2/2025 were reviewed. RN 1 stated bowel and bladder assessments were done on admission, quarterly, and annually. RN 1 stated Resident 66's Care Plan Report indicated the resident was to have a bowel and bladder assessment done on admission, quarterly, and as needed. RN 1 stated Resident 66's last bowel and bladder assessment was performed on 2/14/2025. During a concurrent interview and record review on 6/5/2025 at 3 PM, with the Director of Nursing (DON), Resident 66's Resident 66's Nursing Bowel and Bladder Evaluation dated 2/14/2025 at 9:37 AM and Care Plan Report dated 6/2/2025 were reviewed. The DON stated Resident 66's Care Plan Report indicated the resident was to have a bowel and bladder assessment done on admission, quarterly, and as needed. The DON stated Resident 66's bowel and bladder assessment was last done on 2/14/2025. The DON stated Resident 66's bowel and bladder assessment was not done quarterly. The DON stated resident care plans should be followed because the care plans were an indicative of the care the resident needed. The DON stated there was a potential for the resident to not receive the appropriate care the resident needed if their care plan was not followed. During a review of the facility's Policy and Procedure (P&P) titled Care Plans, Comprehensive Person-Centered dated 1/23/2025, the P&P indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The comprehensive, person-centered care plan: includes measurable objectives and timeframes; describes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . During a review of the facility's P&P titled Urinary Continence and Incontinence - Assessment and Management dated 1/23/2025, indicated The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence .As part of the initial and ongoing assessments, the nursing staff and physican will screen for information related to urinary continence .As part of its assessment, nursing staff will seek and document details related to continence .The nursing staff and physician will identify risk factors for becoming incontinent or for worsening of current incontinence .The evaluation will include a review for medications that might affect continence .The staff and physician will summarize an individual's continence status .As indicated, and if the individual remains incontinent despite treating transient causes of incontinence, the staff will initiate a toileting plan.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and record review the facility failed to ensure one of one sampled residents (Resident 1) had a labeled flush bag for the gastrostomy tube (g-tube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). This failure had the potential for Resident 1 to be exposed to infection. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 05/13/2020 with diagnoses that included aphasia (a communication disorder that impairs a person's ability to process language, affecting their ability to speak, understand, read, or write), dysphagia (difficulty swallowing), and malnutrition (lack of proper nutrition). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/18/2025, the MDS indicated the resident had short and long-term memory problems and severely impaired cognitive (ability to think and process information) skills for daily decision making. During a review of Resident 1's Care Plan Report dated 5/23/2025, the Care Plan Report indicated the resident required tube feeding (g-tube feeding dependent) related to dysphagia, and the nursing interventions were to label the formula container, syringe and administration set with resident's name, date, time, and nurse's initials. During an observation on 6/4/2025 at 10:15 AM with the Treatment Nurse (TN) in Resident 1's room, Resident 1's flush bag was not labeled with the date, time, and nurse's initials which was attached to Resident 1's g-tube pump. During a concurrent observation and interview on 6/4/2025 at 10:35 AM with Licensed Vocational Nurse (LVN) 1, in Resident 1's room, the g-tube feeding and flush were observed. LVN 1 observed that the flush bag was not labeled. LVN 1 stated the flush and feeding were attached to a cassette and placed in the chamber of the pump. LVN 1 stated the risk to Resident 1 without the flush labeled would be not knowing when the flush was hung and possible infection. During an interview on 6/5/2025 at 9:14 AM with the Director of Nursing (DON), the DON stated the g-tube feeding, and flush bag were packaged together and the two should have the date when it was hung for Resident 1. The DON stated the risk to the resident without a labeled flush bag would be possible infection. During a review of the facility's policy and procedures (P&P) titled, Enteral Tube Feeding via Continuous Pump dated 1/23/2025, indicated, on the formula document initials, date and time the formula was hung/administered, and initial that the label was checked against the order. No indication in the policy regarding the labeling of the flush bag.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to: 1. Ensure to receive the receipt of a correct emergency drug supplies (E-kit, a pre-set of medications to provide an immediate service to facility's residents) from the pharmacy upon delivery. As a result, the facility did not have a narcotic (controlled drugs) E-kit available in the facility for roughly twenty-four (24) hours, between 6/2/2025 and 6/3/2025. 2. Ensure an E-kit was replaced within 72 hours of first use. 3. Ensure seven of seven drug disposition forms were filled out with dates of disposition, nurse and witnessing nurse's signatures. 4. Ensure to follow up on Resident 69's Norco (a potent opioid and narcotic that treats pain) 10-325 milligrams (mg, unit to measure mass) ordered on 5/28/2025 until 6/4/2025, after surveyor's inquiry. These failures had the potential to delay treatment and receive medications in error, that may or may not affect the health condition of the residents. Findings: 1. During an interview with the Licensed Vocational Nurse (LVN 1) on 6/03/2025 at 2:13 PM, LVN 1 stated the E-Kit form instructed nurses (in general) to make a copy to keep for facility's record and then place the original form in the kit for pharmacy to retrieve. LVN 1 stated there were separate E-kit log binders for non-narcotic, C-II (controlled drugs class 2, or schedule II-controlled substance, is a type of drug classified by the US drug enforcement administration due to its high potential for abuse and dependence), and narcotic E-kits. During an observation and interview in nursing station 1 medication room on 6/03/2025 at 2:30 PM, there was one drawer labeled CII Ekit and one drawer labeled narcotic e-kit. During a concurrent interview, LVN 1 stated the narcotic E-kit contained non-CII narcotics, such as controlled substance classes 3-5 narcotics. LVN 1 opened the drawer labeled narcotic E-kit and there was a C-II E-kit inside and no narcotic E-kit. During an observation on 6/3/2025 at 2:32 PM, LVN 1 opened the next drawer labeled CII E-kit, and there was a C-II E-kit inside. LVN 1 stated there were a total of two C-II E-kits and no narcotic E-Kit. During an interview on 6/03/2025 at 2:44 PM, with Registered Nurse 1 (RN 1), RN1 stated there was no narcotic E-kit in station 2 (the facility had 2 nursing stations). During a concurrent interview, the Director of Nursing (DON) stated the C-II and narcotic E-kits in station 1 were for both stations to use. During an interview on 6/3/2025 at 4:09 PM, the DON presented a delivery receipt of a narcotic E-kit dated on 6/2/2025 and stated the facility was supposed to receive a narcotic E-kit, however, the pharmacy delivered a CII E-kit instead. During a review of the facility's undated policy and procedures, Medication order records, indicated that . Medications delivered to the facility will be checked off against the Pharmacy order sheet records . The staff member who receives a delivery of medications . sign, date and time a delivery receipt . one copy will be retained at the facility as proof of receipt . Facilities shall maintain a record that includes . date and amount received . 2. During an interview and a concurrent review of the narcotic E-kit logbook with LVN 1 on 6/3/2025 at 2:35 PM, there was one form with two handwritten entries: -4/10/2025 zolpidem (a hypnotic to treat insomnia) 5 mg, two counts, for Resident 27 -3/16/2025 tramadol (a medication to treat pain) 50 mg 2 counts, for Resident 69 LVN 1 stated the dates on the form were about three weeks apart. During an interview on 6/3/2025 at 3 PM, the DON stated the E-kit should be replaced within 72 hours of use, therefore the dates on the same form should not be more than 72 hours apart. During a review of the facility's undated policy and procedures, Medication Orders indicated that . Pharmacy shall provide to facility emergency . medications to provide an immediate service to facility's residents . Drugs used from the kit shall be replaced within 72 hours and the supply resealed by the pharmacist . 3. During an observation and inspection of the station 1 medication room on 6/03/2025 at 2:18 PM with Licensed Vocational Nurse (LVN 1), LVN 1 presented a binder containing disposition logs for non-controlled drugs. During a concurrent review of the disposition logs, it appeared seven (7) pages were incompletely filled out with areas indicated for dates and signatures remained blank. During a concurrent interview, LVN 1 stated three of seven pages did not have two nurses' signatures (1 being witness) and four pages did not have any nurses' signatures nor date of disposition recorded. The surveyor requested a policy and procedures of drug disposition on 6/3/2025 and 6/4/2025 but did not receive the policy. 4. During an observation on 6/4/2025 at 12:02 PM at the mid [medication] cart with LVN 3, LVN 3 opened the narcotic drawer. Inside the drawer, there was a bubble pack (a card that packages doses of medication within small, clear, or light-resistant plastic bubbles or blisters) for Resident 69's Norco 5-325 mg and a bubble pack. During a concurrent review of Resident 69's active orders, LVN 3 stated Resident 69 had active orders for Norco 5-325 mg and Norco 10-325 mg, both dated 5/28/2025. LVN 3 then double checked the narcotic drawer and stated there was no Norco 10-325 mg for Resident 69. During an interview on 6/4/2025 at 12:59 PM, LVN 1 stated Resident 69's Norco 10-325 mg tablets (dated 5/28/25) was pending authorization per pharmacy. The surveyor requested record of communication with the pharmacy. During an interview on 6/4/25 at 4:21 PM, the DON presented an email from the Pharmacy dated 6/4/25 at 1:51 PM, which indicated the pharmacy tried contacting the prescribing doctor on 5/28/2025, 5/29/2025, and 5/30/2025. The DON stated the facility did not have other record of following up with the pharmacy on Resident 69's Norco 10-325mg. During a review of the facility's undated policy and procedures, Medication order records, indicated that The facility shall maintain a record that includes for each drug ordered by prescription . Non-delivery of any item from the Pharmacy will be documented on a 'Non-delivery' form that will identify the reason for the non-delivery and the expected time when the ordered item will be available .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure to follow safe and sanitary food storage and food preparation practices in the kitchen by failing to: 1.Ensure to keep the ice scooper holder clean. 2.Ensure the kitchen staff (in general) did not keep their personal perishable food in the facility's refrigerator and did not place their personal belongings anywhere in the kitchen other than the designated area for staff. These failures had potential for residents at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: 1.During an initial kitchen observation on 6/2/2025 at 7:45 AM and a concurrent interview with the Dietary Food Nutrition Supervisor (DFNS), the DFNS stated the ice scooper holder was dirty. The DFNS stated the facility's Ice Scoop and Container Cleaning Log dated 6/1/2025 and 6/2/2025, indicated the ice scooper and container were cleaned, but the ice scooper holder was dirty. The DFNs stated the ice scooper holder should always be kept clean to prevent contamination. The DFNS stated a dirty ice scooper holder had the potential to cause a break in infection control causing residents to get sick in their stomach. During a review of the facility's Policy and Procedure (P&P) titled Recommended Food Storage Practices - Ice updated on 1/23/2025, indicated all containers used with ice should be kept clean and store in a sanitary manner. 2.During a concurrent interview and observation on 6/2/2025 at 7:45 AM with the DFNS, the surveyor observed a food container covered with aluminum foil with the Dietary Aid (DA) 6/2/2025, handwritten on top of the foil found in the reach-in refrigerator. The DFNS handed the food container to the DA. The DFNS stated the food container belonged to DA. 3.During the concurrent observation on 6/2/2025 at 7:45 AM the surveyor observed a personal tumbler (drink container) sitting on a shelf located in the handwashing station. The DFNS stated a personal tumbler was not allowed in the kitchen area because of contamination. The DFNS stated when personal tumblers were kept in the kitchen area, residents could get sick, they may lose weight when they cannot eat. During a review of the facility's P&P titled Dining Service - Dining Service Overview, updated on 1/23/2025, indicated the facility should offer customers a variety of appetizing, flavorful meals . During a review of the facility's P&P titled Safety and Sanitation: Employee Responsibility for Safety updated on 1/23/2025, indicated employees are not allowed to bring personal items .into the food service production areas.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

2. During a medication administration (med pass) observation on 6/04/2025 at 9:38 AM, the LVN 3 was sanitizing equipment outside of Resident 32's room. Next to Resident 32's name posted on the wall by the entrance was in orange paper which was different than other residents. During a concurrent interview, LVN 3 stated the orange color meant Resident 32 required enhanced barriers precautions which meant clinicians (staff) needed to gown up before providing care to the resident. Surveyor pointed out the name of the resident observed during the previous med pass (Resident 69) was also on orange paper. LVN 3 stated Resident 69 name was in orange paper and stated she (LVN3) forgot to don (put on) a gown. During an interview on 6/04/2025 at 9:48 AM, RN 1 stated the med pass process was considered direct patient care and thus required the enhanced barrier precautions. During an interview on 6/04/2025 at 4:01 PM, the infection preventionist (IP, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment) stated the med pass process including taking vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) were considered direct care, which would require the clinician to don on barrier, as in gown and gloves, before entering the room or attending to the residents. During a review of the facility's policy and procedures, Enhanced Barrier Precautions (dated April 2025), indicated Enhanced Barrier Precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents . EBPs employ targeted gown and glove use in addition to standard precautions . 3.During a medication administration (med pass) observation and interview on 6/05/25 at 8:43 AM, RN 2 was preparing for Resident 32's medication administration of vancomycin. RN 2 connected the vancomycin vial with the 250 milliliters (ml, unit to measure volume) bag of normal saline (a 0.9 % sodium chloride solution used to reconstitute medication for intravenous administration) and did not use alcohol swab on vial top. RN 2 also did not disinfect the injection ports before connecting tubing to the ports. RN 2 stated it was not necessary to disinfect with alcohol. During an interview on 6/05/2025 at 10:40 AM, IP stated all injection ports should be disinfected during preparation and administration of the IV medication. During a review of the facility's undated policy, Infection Control Universal Precautions, indicated that . Strict aseptic technique shall be used when accessing all injection ports . All injection ports, peripheral and central, shall be disinfected with a sterile alcohol swab using a vigorous rub for no less than 30 seconds . Based on interview and record review, the facility failed to follow infection control practices by failing to: 1. Develop a sufficient water management plan (a program that identifies hazardous conditions and steps to take to minimize the growth and spread of waterborne pathogens in building water systems) to reduce the growth and spread of Legionella (bacteria that causes Legionnaires Disease, a severe lung infection. Legionella is often found in water systems and is spread by breathing in mist or swallowing water that is contaminated by the bacteria) amongst 97 out of 97 facility residents. 2.Ensure the nursing staff (Licensed Vocational Nurse 3 [LVN3]) followed its enhanced barriers precautions (EBP, an infection prevention protocol) policy during the medication administration observation for one of five sampled residents (Resident 69). 3. Ensure Registered Nurse2 (RN2) would disinfect the injection ports during the preparation of an intravenous (IV, into the vein) vancomycin (an antibiotic to treat certain infections) for one of one sampled resident (Resident 32). These failures had the potential to spread infections and had the potential for Legionella growth and spread amongst the residents. Findings: 1.During a review of the facility's Water Management Plan dated 3/2024, the Water Management Plan indicated the facility was built in 1970, had two floors, one water feature, and a central cooling system. The Water Management Plan indicated the Administrator, Director of Nursing (DON), Infection Preventionist (IP, a healthcare professional who specializes in preventing and controlling the spread of infection), and Environment Services (EVS) Director were part of the water management team. The Water Management Plan indicated a flow diagram (a visual representation of a process or workflow) that showed where the facility's main water source was located and where water exited the building. The Water Management Plan indicated three steps that included identifying the water source, testing areas open to residents, and sharing test results with the IP. The Water Management Plan indicated that it must be reviewed every 12 months to ensure tests were conducted every 90 days, or as required by the water management team. The Water Management Plan indicated every faucet must have aerators (a device that is attached to a faucet or showerhead to mix air with water creating a more softer and consistent water stream) replaced every six to nine months. The Water Management Plan indicated a test would be conducted by the Maintenance Director or Regional EVS technician. The Water Management Plan did not include descriptions of the building, who the building primarily housed, or the building's water system. The Water Management Plan did not identify areas where Legionella could grow and spread, control measures (actions aimed to eliminate hazards and risks), or verification steps to ensure the Water Management Plan was being followed. During a concurrent interview and record review on 6/5/2025 at 2:40 PM with the IP, the facility's Water Management Plan dated 3/2024 was reviewed. The IP stated the Water Management Plan did not include descriptions of the building, who the building primarily housed, or the building's water system. The IP stated the Water Management did not identify areas where Legionella could grow and spread, control measures, or verification steps to ensure the Water Management Plan was being followed. The IP stated the Water Management Plan was not sufficient or personalized to the facility's water system. During a concurrent interview and record review on 6/5/2025 at 3:25 PM with the Administrator, the facility's Water Management Plan dated 3/2024 was reviewed. The Administrator stated the Water Management Plan did not include descriptions of the building, who the building primarily housed, the building's water system, areas where Legionella could grow and spread, control measures, or verification steps to ensure the Water Management Plan was being followed. During a concurrent interview and record review on 6/5/2025 at 3:30 PM with the Director of Nursing (DON), the facility's Water Management Plan dated 3/2024 was reviewed. The DON stated the Water Management Plan did not include descriptions of the building, who the building primarily housed, the building's water system, areas where Legionella could grow and spread, control measures, or verification steps to ensure the Water Management Plan was being followed. The DON stated the Water Management Plan was not sufficient or personalized to the facility. The DON stated that there was a potential for the facility to experience infection control issues if the Water Management Plan was not sufficient or personalized to the facility's water system. During a review of the facility's Policy & Procedure (P&P) dated 1/23/2025 titled Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings: A Practical Guide to Implementing Industry Standards, the P&P indicated Survey your building to determine if you need a water management program to reduce the risk of Legionella growth and spread .Developing a maintain a water management program is a multi-step, continuous process .You need to review the elements of your program at lead once per year .Describe your building water systems using text .You will need to write a simple description of your building water system and devices you answered yes to on page 2. This description should include details like where the building connects to the municipal water supply, how water is distributed, and where pools, hot tubs, cooling towers, and water heaters or boilers are located. An existing as-build diagram of the plumbing system and fixture may be useful in developing this description .In addition to developing a written description of you building water systems, you should develop a process flow diagram .Once you have developed your process flow diagram, identify where potentially hazardous conditions could occur in you building water systems .Each potentially hazardous condition should be addressed individually with a control point, measure, and limit .Your written program should include at least the following: Program team, including names, titles, contact information, and roles on the team. Building description, including location, age, uses, and occupants and visitors. Water system description, including general summary, uses of water, aerosol-generating devices (e.g. hot tubs, decorative fountains, cooling towers), and process flow diagrams. Control measures, including points in the system where critical limits can be monitored and where control can be applied. Confirmatory procedures, including verification steps to show that the program is being followed as written and validation to show that the program is effective. Document collection and transport methods and which lab will perform the testing if environmental testing is conducted.

Apr 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review the facility failed to administer medication as ordered by the physician for one of five sampled residents (Resident 1). For Resident 1, the facility failed to administer the Benadryl (medication that treats the symptoms of allergies and allergic reaction) 25 milligrams (mg., metric unit of measurement, used for medication dosage and/or amount) on 3/28/25 when Resident 1 complained of facial itching due to possible allergic reaction. This deficient practice had the potential for Resident1 to continue experiencing allergic reaction and discomfort. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 1/6/25 with diagnoses including fibromyalgia (chronic long-lasting disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping) and other disturbances of skin sensation. During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 1/13/25 indicated Resident 1 was cognitively intact. Resident 1 needed substantial assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear and moderate assistance (helper does less than half the effort) with eating, oral hygiene, upper body dressing and personal hygiene. During a review of Resident 1 ' s Change in Condition Evaluation (CIC) dated 3/28/25 at 12:30 p.m. indicated Resident 1 complained of itching of face due to possible allergen. The CIC indicated Resident 1 had no swelling of the face, hands or throat. Resident 1 had no rash. The CIC indicated Resident 1 ' s primary physician was notified and gave order to give Resident 1 Benadryl 25 mg. orally every six hours for 14 days as needed for itching. During a review of Resident 1 ' s Physician Order dated 3/28/25 at 12:30 p.m., indicated an order to give Resident 1 Benadryl 25 mg. one tablet by mouth every six hours for 14 days as needed for itching. During a review of Resident 1 ' s care plan initiated on 3/28/25 indicated Resident 1 had itching of the face due to possible allergen. The care plan goal indicated Resident 1 will not have itching of the face. Intervention included to administer Benadryl 25 mg. orally every six hours for 14 days as needed for itching. During a review of Resident 1 ' s Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), the MAR for the Benadryl was not signed as given on 3/28/25. During a telephone interview on 4/17/25 at 3:29 p.m., Resident 1 stated she had an allergic reaction to the food she ate. Resident 1 stated the facility did not give her Benadryl. During an interview on 4/18/25 at 10:09 a.m., licensed vocational nurse (LVN 1) stated on 3/28/25, Resident 1 complained of itching in the face. LVN 1 stated Resident 1 may have had possible allergic reaction to the food. LVN 1 stated she assessed Resident1 ' s mouth and found no swelling or redness. LVN 1 stated she notified Resident 1 ' s primary physician and received order to administer Benadryl 25 mg. orally as needed for itching. LVN 1 stated she administered the Benadryl 25 mg. to Resident 1. During concurrent interview and record review on 3/18/25 at 11:45 a.m. with the registered nurse supervisor (RNS 1) Resident 1 ' s physician order for Benadryl dated 3/28/25 was reviewed. RNS 1 stated Resident 1 had a possible allergic reaction on 3/28/25. RNS 1 stated, Resident 1 ' s primary physician was notified. The primary physician gave order to give Resident 1 Benadryl 25 mg every 6 hours as needed for itching. RNS 1 stated once the Benadryl was given to Resident 1, the MAR should be signed to indicate the Benadryl was given. During concurrent interview and record review on 4/18/25 at 1:47 p.m., Resident 1 ' s MAR dated 3/28/25 and physician order for Benadryl dated 3/28/25 were reviewed with the director of nursing (DON). The DON agreed the MAR was not signed as given on 3/28/25 and there was no other documentation to indicate the Benadryl 25 mg was given on 3/28/25. The DON stated if Benadryl was not given Resident 1 may potentially the itching will get worst. During a review of the facility's policy and procedures (P&P) titled Administering Medications reviewed on 1/23/25, the P&P indicated the individual administering the medication initials the residents MAR on the appropriate line after giving each medication and before administering the next ones. The same Policy indicated as required or indicated for a medication, the individual administering the medication records in the resident ' s medical record: a. the date and time the medication was administered b. dosage c. the route of administration e. any complaints or symptoms for which the drug was administered f. any results achieved and when those results were observed g. the signature and title of the person administering the drug.

Nov 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Staffing Information (Tag F0732)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to post the federally required daily actual hours worked by the staff in an area accessible to the public for one of one sampled day (11/12/2024). As a result, the actual hours worked by the staff was not readily accessible to residents, family, or visitors. Findings: During an observation of the facility on 11/12/2024 at 10:46 a.m , no Direct Care Services Hours Per Patient Day (DHPPD) actual hours were posted in the DHPPD posting, there was no DHPPD posted for the previous day (11/11/2024). During an interview with Director of Staff and Development (DSD) on 11/12/2024 at 11:20 a.m., DSD stated, the NHPPD posting were on the wall with only the projected hours. The DSD stated, she was not sure if the DHPPD posting had to include the actual hours and if the DHPPD posting for the previous day also had to be posted. During a follow-up observation of the facility on 11/12/2024 at 11:22 a.m., DHPPD were observed posted on the wall with the projection hours information. No actual hours were posted in the DHPPD posting. During an interview with the Director of Nursing (DON) on 11/12/2024 at 1:13 p.m., the DON stated, the DHPPD posting were posted daily with the projection hours for that day. The DON stated the actual hours were not required to be posted in the DHPPD. When asked what the facility policy indicated, the DON read the policy and stated, the actual hours had to also be posted for the previous day (11/11/2024) along with the projection hours of the current day (11/12/2024). A review of the facility ' s policy and procedure (P&P) titled Posting Direct Care Daily Staffing Numbers reviewed on 1/18/2024, the P&P indicated, Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include: The actual time worked during that shift for each category and type of nursing staff . The previous shift' s forms shall be maintained with the current shift form for a total of 24 hours of staffing information in a single location.

Jul 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a system to consistently and accurately reconcile Pomalyst (pomalidomide- is an oral chemotherapeutic (a drug used to treat cancer) capsule treatment for Multiple Myeloma [a blood cancer that develops in plasma cells in the bone marrow]) oral capsule (cap) 4 Milligrams (MG) for one of the three sampled residents (Resident 1). This failure resulted in Resident 1 missing a total of 2 dosages on 5/18/24 and 7/13/24. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Multiple Myeloma, type 2 diabetes mellitus (DM2 - a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), and end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). A review of the history and physical (a term used to describe a physician's examination of a patient. The physician obtains a thorough medical history from the patient, performs a physical examination, and then documents their findings) dated 3/18/24 indicated Resident 1 had the capacity to understand and make decisions. A review of the physicians order dated 5/7/24 indicated, Pomalyst Oral Capsule 4 MG{Pomalidomide). Give 1 capsule by mouth in the evening every Mon, Wed, Fri for multiple myeloma for 21 Days. A review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 6/23/24, indicated Resident 1 had some sever cognitive impairments (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 1 required between substantial maximum assistance to setup or clean up assistance for Activities of Daily Living (ADLs-eating, oral hygiene, personal hygiene, shower/bathe self). A review of the physician order dated 7/11/24 indicated, Pomalyst Oral Capsule 4 MG (Pomalidomide) Give 1 capsule by mouth one time a day every Mon, Wed, Fri for multiple myeloma for 21 Days Give on empty stomach. Wear gloves when handling medication. Do not open, crush or chew capsule. Give for 21days, rest for 7 days, continue with 21 days again indefinitely. During an interview with Resident 1 on 7/17/24 at 9:20 am, Resident 1 stated that he was prescribed the Pomalyst by his oncologist (a doctor who diagnoses and treats cancer) during the 5/24 appointment. Resident 1 stated that he was not receiving the Pomalyst as prescribed at the facility. During a concurrent interview and record review of the Medication Administrative Record (MAR- a report that includes key information about the individual's medication including, the medication name, dose taken, special instructions and date and time) for the month of 5/24 and 7/24 for Resident 1 with the Director of Nursing (DON) on 7/17/24 at 12:08 pm, the DON confirmed that the medication was not administered on 5/18/24 and 7/13/24 as ordered. During a concurrent interview and record review of Resident 1 ' s 7/24 MAR on 7/17/24 at 2:18 pm with Licensed Vocational Nurse (LVN) 2, LVN 2 admitted that she had not administered the Pomalyst on 7/13/24 because she was unable to find it in the medication cart. LVN 2 stated that she thought the medication was unavailable until another LVN showed it to her the following day. During an interview with the pharmacist (PharmD) on 7/17/24 at 2:30 pm, PharmD stated that Pomalyst must be given as prescribed without skipping doses otherwise, there was a high risk for Resident 1 experiencing side effects such as: neutropenia (a condition where you have a low number of white blood cells called neutrophils in your blood), infection, constipation, muscle pain, blood clots, electrolyte imbalance. During a review of the facility's policy and procedures (P&P) titled Administering Medications, with a reviewed 2024 indicated, Medications are administered in a safe and timely manner, and as prescribed. The same P&P indicated policy interpretation and implementations which included medications are administered in accordance with prescriber orders, including any required time frame.

Jun 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, facility failed to ensure dignity and respect for two of seven sampled residents (Residents 2 and 7). This failure resulted in Residents 2 and 7 not being treated with dignity and respect and had the potential to affect the resident ' s self-esteem and self-worth. Findings: A review of Resident 2 ' s admission Record dated 6/24/24, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including, hypertension (high blood pressure), low back pain, anemia (a condition in which the body does not have enough healthy red blood cells, to transport oxygen around the body) and cellulitis (bacterial infection that enters your skin and tissue through a wound) of bilateral (both) lower extremities. A review of Resident 2 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/30/24 indicated Resident 2 had intact cognition (ability to think, understand and make daily decisions). The same MDS indicated Resident 2 required set up assistance from staff for eating, and supervision for bed mobility, toileting, dressing, and personal hygiene. A review of Resident 7 ' s admission Record dated 6/26/24, indicated Resident 7 was admitted to the facility on [DATE], with diagnoses including, osteoarthritis (a type of arthritis that happens when the cartilage that lines your joints is worn down and your bones rub against each other) of right hip, anemia, reduced mobility (moving around), and lack of coordination. A review of Resident 7 ' s MDS dated [DATE] indicated Resident 7 had intact cognition. The same MDS indicated Resident 7 required set up assistance from staff for eating, and maximal to being totally dependent on staff for bed mobility, toileting, dressing, and personal hygiene. During an interview on 6/24/24 at 12:46 pm with, Resident 2, Resident 2 mentioned there was an incident early morning 6/18/24 when she was called into a resident ' s room to help because they were cold. The resident stated she found the resident uncovered and helped cover them. When a Certified Nursing Assistant (CNA) came into the room and yelled at them both as to why they were questioning his care. The resident further stated they (staff) all yell frequently on the night shift, and they should not be doing that. During an interview on 6/26/24 at 6:45 am with Resident 7, Resident 7 stated she had heard and argument between more than two people around the same time Resident 2 stated the yelling took place. Resident 7 stated she didn ' t know what they were saying but it was an argument. A review of the facility ' s policy and procedures (P&P) titled, Resident rights, revised on 12/2016, indicated Employees shall treat all residents with kindness, respect and dignity . Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s rights to be treated with respect, kindness, and dignity.

May 2024 11 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify and ensure one of three closed record residents (Resident 75), who had an amputation site (surgical removal of part of the body, left lower leg), acute respiratory failure with hypoxia (a condition where you do not have enough oxygen in the tissues in your body), and a right lateral malleous (bony projection of the ankle) with arterial ulcer (injury to skin or underlying tissue caused by poor circulation, which in turn was caused by arterial insufficiency [reduced blood flow by the artery]) on the right lower leg, received necessary care and services in accordance with professional standards of practice by failing to: -Assess upon admission or on [DATE], and document the condition, description, and measurements of Resident 75's right lateral malleous arterial ulcer of the right lower leg, as documented on the admission Data Collection form dated [DATE]. -Develop a comprehensive and person-centered Care Plan to include the Physician's Order for treatment to Resident 75's right lateral malleous arterial ulcer. - Follow the Physician's Order for treatment to Resident 75's right lateral malleous lower leg arterial ulcer (a painful, deep sore or wound in the skin of the lower leg or foot), cleanse with normal saline (a mixture of sodium chloride [salt] and water), pat dry, apply Medi honey (supports the removal of necrotic tissue and aids in wound healing), cover with dry dressing, every day shift for 21 days. -Assess respiratory status for accurate rate of oxygen administration and monitor Resident 75 for any changes in condition (shortness of breath), per the Continuous Oxygen Therapy care plan developed on [DATE]. As a result, Resident 75 did not receive treatment to the right lateral malleous arterial ulcer of the right lower leg for over two weeks and was transferred to General Acute Care Hospital (GACH) 2 for altered level of consciousness (ALOC, resident is not as awake, alert, or able to understand or react to the surrounding environment). At the GACH 2, Resident 75 complained of shortness of breath, required four liters per minute of oxygen via nasal cannula (NC, a device that gives you additional [supplemental] oxygen through your nose) with 92% oxygen saturation (amount of oxygen traveling through the body in your red blood cells, normal oxygen saturation for a healthy adult between 95% and 100%) and complained of right ankle pain. The GACH 2 Emergency Department Note dated [DATE], indicated Resident 75 developed soft tissue ulceration (formation of a break on the skin or on the surface of an organ) overlying the side of the smaller thinner calf bone (lateral malleous) with underlying osteomyelitis (inflammation or swelling of bone tissue that is usually the result of an infection), abnormal accumulation of fluid in the pleural space (the cavity between the lungs and chest wall) with pulmonary edema (fluid builds up in the lungs) and adjacent atelectasis (collapse of the whole lung or an area of the lung). Resident 75 died three days later on [DATE]. Findings: A review of General Acute Care Hospital (GACH) 1 Hospitalist Progress Note dated [DATE], indicated Resident 75 was status post cardiac arrest (heart attack) and received two thoracenteses (procedure to remove fluid or air from around the lungs) with the last procedure on [DATE]. The GACH 1 progress note indicated Resident 75 was on three antibiotics for a diabetic infection of the left foot with questionable osteomyelitis (bone infection). A review of Resident 75's GACH 1 Complex Case Manager Note dated [DATE], indicated the resident needed placement for physical therapy and wound care at the amputation site (surgical removal of part of the body, left lower leg). The note indicated Resident 75 should be able to return home with the help of family when independent. A review of Resident 75's GACH 1 Physician's Transfer Orders form dated [DATE], indicated the resident had hypoxia (oxygen levels in the blood are lower than normal) when sleeping and required oxygen at two liters per minute when awake during the daytime. The Transfer Orders indicated the resident was not on antibiotics during to the transfer. According to a review of the admission Record to the facility Resident 75 was admitted on [DATE], with diagnoses including non-pressure chronic ulcer of the right lower leg (caused by poor circulation, which in turn was caused by venous or arterial insufficiency), after care following surgical amputation of the left lower leg and acute respiratory failure with hypoxia (a condition where you do not have enough oxygen in the tissues in your body). A review of Resident 75's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated [DATE], indicated Resident 75's cognition was intact (sufficient judgement and self-control to manage the normal demands of the environment) was dependent on facility staff with showering and transfers. The MDS indicated Resident 75 had one arterial ulcer (right leg), a surgical wound with application of nonsurgical dressings (left leg amputation) and required oxygen therapy. A review of Resident 75's admission Data Collection form documented by the admission Nurse dated [DATE], indicated Resident 75 had clear lung sounds, no shortness of breath, and had 98% oxygen saturation on room air. The admission Data Collection form indicated the resident was not on antibiotics, was a full code (if a person's heart stopped beating and/or they stopped breathing, all procedures would be provided to keep them alive), and had a right ankle diabetic ulcer. The admission Data Collection form did not indicate Resident 75's right lateral malleous with arterial ulcer to the lower right leg. A review of the Physician's Order dated [DATE], indicated for Resident 75 to receive treatment on the right lateral malleous with arterial ulcer (a painful, deep sore or wound in the skin of the lower leg or foot), cleanse with normal saline (a mixture of sodium chloride [salt] and water), pat dry, apply Medi honey (supports the removal of necrotic tissue and aids in wound healing), cover with dry dressing, every day shift for 21 days. According to a review of Resident 75's Treatment Administration Record (TAR), Resident 75 received treatment to the right lateral malleous with arterial ulcer on [DATE]. Further review of the TAR indicated the resident did not receive the Physician's Ordered treatment from 3/18 to [DATE] (14 days). A review of Resident 75's History and Physical (H&P) dated [DATE], indicated Resident 75 had the capacity to understand and make decisions. A review of the Physician's Order dated [DATE], indicated Resident 75 was to receive oxygen at two liters per minute via NC continuously. May titrate up to three liters per minute, every shift for hypoxemic respiratory failure. A review of Resident 75's admission Data Collection Form documented by the Treatment Nurse (Licensed Vocational Nurse 8) dated [DATE], indicated a head-to-toe assessment was completed, four days after admission. The form indicated the resident denied pain, wound care was rendered (but there was no indication of the location of the wound) and tolerated well. The admission Data Collection form indicated the resident had a left below the knee amputation (BKA) with staples and a skin abrasion (the surface layers of the skin [epidermis] has been broken) on the left flank (space between the lowest rib and hip). The admission Data Collection form documented by the Treatment Nurse did not indicate a right ankle diabetic ulcer on the admission Data Collection form dated [DATE] documented by the admission Nurse, nor did it indicate the condition, description, or any measurements of the right lateral malleous with arterial ulcer to the lower right leg. A review of a care plan dated [DATE] indicated Resident 75 wanted to return the the community. The care plan intervention indicated to assess discharge plan needs with the resident and Interdisciplinary Team members. According to a review of Resident 75's Continuous Oxygen Therapy care plan developed on [DATE], for the resident's acute respiratory failure with hypoxia, the goal indicated for the resident to have no signs or symptoms of poor oxygen absorption. The care plan interventions indicated to monitor for signs and symptoms of respiratory distress and assess respiratory status for rate, depth, and ease and report to the doctor. A review of Medication Administration Record (MAR) dated [DATE] indicated Resident 75 received two liters of oxygen via nasal cannula and on the evening shift the resident's oxygen saturation was 98%, but the oxygen inhalation section indicated 96%. The MAR dated [DATE] indicated on the morning shift Resident 75's oxygen saturation was 98% but the oxygen inhalation was 96% and during the night shift (same date) the oxygen saturation was 98% and oxygen inhalation was 97%. This indicated discrepancies in the monitoring of the resident's respiratory status. A review of Resident 75's At Risk for Skin Breakdown care plan developed on [DATE] (almost three weeks after admission), for the resident's right lower leg with scattered arterial ulcers, had a goal for the resident to minimize the risk of skin breakdown every day. The care plan interventions indicated handling the resident gently during care, keep skin clean, dry, and comfortable at all times, and report any redness or open area. The care plan did not include the Physician's Order to provide treatment every day for 21 days to the right lateral malleous with arterial ulcer of the resident's right lower leg. A review of Resident 75's Social Services Note dated [DATE], indicated discharge planning was in progress with the resident's family member and the discharge plan was to go to a lower level of care. A review of Resident 75's Weekly Wound Note dated [DATE], indicated the resident's right lateral malleous with arterial ulcer of the resident's right lower leg had scant amount of serosanguineous (contains both blood and liquid part of blood [serum]) exudate (fluid that leaks out of blood vessels into nearby tissues), the surrounding skin condition was normal, and not painful. The Weekly Wound Note indicated all needs were attended to and there were no signs or symptoms of infection. According to a review of the TAR dated [DATE], Resident 75's right lateral malleous with arterial ulcer of the resident's right lower leg was provided treatment. This indicated the resident did not receive treatment for the arterial ulcer for over one month, as the last treatment documented was [DATE]. Further review of the TAR indicated Resident 75 did not receive the Physician's Ordered treatment from [DATE] to [DATE]. A review of Resident 75's Weekly Wound Note dated [DATE], indicated the resident's right lateral malleous with arterial ulcer of the resident's right lower leg had scant amount of serosanguineous exudate, the surrounding skin condition was fragile (which indicated a change). The Weekly Wound Note indicated all needs were attended to and there were no signs or symptoms of infection. A review of the MAR dated [DATE] for the morning shift indicated there was no documentation regarding Resident 75's oxygen saturation. For the afternoon shift the MAR indicated the resident received oxygen at two liters per minute, the oxygen saturation was 97% and under oxygen inhalation was 98%. A review of Resident 75's Nursing Progress Note dated [DATE] at 11:05 AM, indicated the resident was alert and oriented, did not have signs or symptoms of acute distress or pain, and the resident's vital signs were within normal limits. The Nursing Progress Note indicated the resident was receiving oxygen via NC (with no documentation regarding the amount of oxygen administered to the resident) and the oxygen saturation was 97%. A review of the Change of Condition (COC, a sudden clinically important decline from a patient's baseline in physical, cognitive, or functional abilities) Record dated [DATE] at 8:15 PM, indicated Resident 75 was found on the floor in a supine position (lying on the back or with the face upward). The COC indicated the resident did not have shortness of breath and was on continuous oxygen. The COC indicated under the vital signs portion the resident had an oxygen saturation of 97% and was on room air. The COC indicated at 8:25 PM, Resident 75 was noted with altered level of consciousness (the resident is not as awake, alert, or able to understand or react to the surrounding environment) and the facility obtained doctor's orders to send the resident out for a computerized tomography scan (CT, diagnostic imaging procedure to produce images of the inside of the body) of the head. According to a review of the Physician's Order dated [DATE], Resident 75 was to be transferred to the GACH due to altered level of consciousness. A review of the GACH 2 Emergency Department Note dated [DATE], indicated Resident 75 presented with cough, congestion and required four liters per minute of oxygen via NC at baseline (this indicated the facility should have given the resident four liter of oxygen continuously). The ED Note indicated an x-ray of the chest was done with findings including bilateral pleural effusions (abnormal accumulation of fluid in the pleural space) with pulmonary edema and adjacent atelectasis (collapse of the whole lung or an area of the lung). The note indicated an x-ray of the right ankle was done with findings including soft tissue ulceration (formation of a break on the skin or on the surface of an organ) overlying the lateral malleous (the bone on the outside of the fibula) with underlying lateral malleous osteomyelitis. A review of Resident 75's GACH 2 H&P Note dated [DATE], indicated the resident complained of shortness of breath required four liters of oxygen via NC with 92% oxygen saturation and complained of right ankle pain due to osteomyelitis. A review of Resident 75's GACH 2 Discharge Summary Note dated [DATE], indicated the resident was admitted to GACH 2 with shortness of breath and right ankle pain. The Note indicated a diagnoses of acute respiratory failure with hypoxia, severe bilateral pleural effusion, and chronic osteomyelitis. The note indicated the resident expired (the last emission of breath, death) on [DATE] (three days after transfer from the facility). During a concurrent interview and record review, on [DATE] at 11:58 AM with the Quality Assurance (QA) Nurse, Resident 75's Physician's Order Report dated [DATE] was reviewed. The QA Nurse stated the treatment order for the resident's right lateral malleous with arterial ulcer of the resident's right lower leg should have been clarified with the physician. The QA Nurse stated instead of the treatment order indicating every 21 days for 21 days, the order should have indicated every day for 21 days. During a review of Resident 75's admission Data Collection Form dated [DATE], the QA Nurse stated the licensed nurse did not perform an accurate assessment for Resident 75 and was missing some assessments on the form. The QA Nurse stated there was no admission assessment regarding Resident 75's right lateral malleous with arterial ulcer of the resident's right lower leg. During a concurrent interview and record review, on [DATE] at 12 PM, a review of Resident 75's TAR dated [DATE] and [DATE] were reviewed. The QA Nurse stated the first treatment for the right lateral malleous with arterial ulcer of the resident's right lower leg given to Resident 75 was on [DATE] and no other treatment was provided for the remainder of the month. The QA Nurse stated if the treatment was not documented then the treatment was not provided, and based on the TAR, the treatment was not given to Resident 75. The QA Nurse stated treatment for the month of April was documented on [DATE] and not documented on any other day. The QA Nurse stated the TAR looked like the staff was providing treatment every 21 days. During an interview on [DATE] at 12:16 PM, when asked about the importance of Resident 75's care plan for the right lateral malleous with arterial ulcer of the resident's right lower leg, the Director of Nursing (DON) stated the purpose of the care plan was to identify Resident 75's wounds and identify interventions for those wounds. The DON stated if the care plan was not initiated upon admission, the facility could not show what interventions were carried out for each wound, and the outcome could result in the resident having an infection. On [DATE] at 12:45 PM, during an interview, when asked about the Physician's Order for Resident 75's treatment of the right lateral malleous with arterial ulcer of the resident's right lower leg, the Medical Director (MD) stated the treatment order should have been clarified with the physician because the facility follows a protocol when writing orders. The MD stated instead of the treatment order indicating every 21 days for 21 days, the order should have indicated every day for 21 days. During a concurrent interview and record review on [DATE] at 3:17 PM with LVN 4, Resident 75's Physician's Order Report dated [DATE] was reviewed. LVN 4 stated the protocol was to provide treatment every day and the facility staff would re-evaluate on the 21st day. LVN 4 stated the frequency, and the schedule type was incorrect on the order and the order should have been clarified with the physician. During a review of Resident 75's TAR, dated [DATE] and [DATE], LVN 4 stated if the treatment was not documented, then the treatment was not done. LVN 4 stated, It was not okay that the treatment was not provided, as this could cause Resident 75's wound to get worse or infected and could cause pain. During an interview on [DATE] at 3:48 PM, the MD stated the treatment for osteomyelitis was six weeks of antibiotics unless the source of the osteomyelitis was known. The MD stated for Resident 75 the osteomyelitis was in the left leg and that was why the resident underwent a BKA. The MD stated after surgery, if there were no complications, then antibiotics would not be needed and that was why Resident 75 was not transferred to the facility with antibiotic orders. The MD stated once the infection was gone, the treatment was to discontinue antibiotics and let the resident heal. During an interview on [DATE], with LVN 8 (treatment nurse) who completed Resident 75's admission Data Collection Form on [DATE], stated upon admission Resident 75 had scattered ulcers, and a lateral malleous arterial ulcer to the right lower leg. LVN 8 stated the resident's right lower leg ulcers were not documented on the admission Assessment completed by LVN 8 and was not an accurate assessment because the admission Data Collection Form did not reflect all of Resident 75's wounds. When asked about the Physician's Order for Resident 75's treatment, LVN 8 stated the Physician's Order was incorrect, as LVN 8 obtained the order from the MD and stated the order was inputted incorrectly. LVN 8 stated it was important to clarify the physician's orders and if the resident did not receive the treatment as ordered, the resident was at risk for infection. A review of the facility's undated policy and procedures (P&P) titled, admission Assessment and Follow Up: Role of the Nurse, indicated steps to conduct an admission assessment include a list of active medical diagnoses and patient problems, especially those most related to reasons for admission to the facility and those affecting function, quality of life, ability to participate in activities, and to socialize. The policy indicated to include current medications and treatment, to reconcile the list of medications from the medications history, admitting orders, and the previous MAR from previous institution according to established procedures. The policy indicated to contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings. A review of the facility's undated P&P titled, Care Plans, Comprehensive Person-Centered, indicated the interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The policy indicated the care plan interventions were chosen only after gathering proper sequencing of events, careful consideration of the relationship between the residents problem areas and their causes, and relevant clinical decision making. The policy indicated when possible, interventions address the underlying source of the problem area, not just symptoms or triggers. A review of the facility's P&P titled, Treatment Nurse - LVN Job Description, dated [DATE], indicated to provide treatment and therapeutic services per the physician's orders and to meet with and solicits advice from the Medical Director, DON, and wound care consultants concerning care of residents.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review, the facility failed to develop an individualized person-centered care plan to meet the resident's needs for one of five sampled residents (Resident 40). This deficient practice had the potential to lead to the inadequate care of Resident 40. Findings: A review of Resident 40's admission Record (Face Sheet) indicated the facility admitted the resident on 7/20/2022, with diagnoses including Type II diabetes (a disease that occurs when the sugar level is high in the blood), unsteadiness on feet, and major depressive disorder (a mental health condition that causes a low mood and a loss of interest in activities that once brought joy). A review of the Physician's Orders dated 3/6/2024, indicated to administer insulin glargine (long-acting insulin, a medicine used to control the amount of sugar in the blood of patients with diabetes for the entire day) 20 units (a measurement for insulin) subcutaneously (SQ- to inject under all the layers of the skin) every 12 hours for Type II diabetes. A review of the Physician's Orders dated 3/7/2024, indicated to administer insulin lispro (a rapid-acting insulin, a medicine used to control the amount of sugar in the blood of patients with diabetes. It starts to work very quickly, and you take it before meals to stop your blood sugar from going too high) 5 units subcutaneously before meals for Type II diabetes. A review of the Situation Background Assessment and Recommendation Communication Form (SBAR- a written communication tool that helps provide important information ) dated 3/7/2024, indicated Resident 40 had an elevated uncontrolled blood sugar of 495 milligrams per deciliter (mg/dl-unit of measurement [ normal range for a diabetic according to American Diabetes Association: 80-130 mg/dl]). A review of Resident 40's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 3/25/2024, indicated the resident's cognitive skills for daily decision making was moderately impaired (decisions poor, cues/supervision required) and required maximal assistance with toileting hygiene, upper body dressing, showering and bathing. The MDS indicated Resident 40 required staff supervision when eating. A review of Resident 40's Care Plans on 5/8/2024, indicated there was no individualized person-centered care plan for hyperglycemia (abnormal high blood sugar) including measurable objectives, monitoring, or interventions to meet resident's needs. During a concurrent interview and record review on 5/8/2024 at 12:51 PM, with Registered Nurse Supervisor 1 (RN1), Resident 40's care plans were reviewed. RN 1 stated staff did not develop a care plan for hyperglycemia after Resident 40 had a change of condition (COC) on 3/7/2024. RN 1 stated licensed staff were required to develop a care plan with interventions for hyperglycemia and that the potential outcome was a lack of care and monitoring for Resident 40. During an interview on 5/8/2024 at 3:13 PM, the facility's Director of Nursing (DON) stated licensed staff were required to develop a care plan with appropriate interventions when a resident had a change of condition. The DON further stated licensed nurses were required to implement the care plan interventions and also to evaluate the effectiveness of the interventions. The DON stated, Licensed staff did not develop a care plan for Resident 40 after he had high blood sugar level on 3/7/2024, and the potential outcome was lack of care and delivery of necessary services. A review of the facility's undated policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, indicated assessments of the residents were ongoing and care plans were revised as information about the residents and the residents conditions changed. The interdisciplinary team reviews and updates the care plan when there was a significant change in the resident's condition.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1), who recieved treatment for a right heel deep tissue injury (DTI - purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from prolonged pressure and/or shear), received necessary care and services per the comprhensive assessment and in accordance with professional standards of practice by failing to: -Implement the 'At Risk for Further Impaired Skin Integrity' Care Plan interventions, including to monitor / document / report changes in wound color, drainage, odor, sensation, or pain, and measurement of the DTI weekly, for 16 days (from 6/4 - 6/20/2024). This deficient practice caused an increased risk in complications of Resident 1's plan of care. Findings: A review of Resident 1's admission Record indicated the facility originally admitted the resident on 5/21/2024 and re-admitted the resident on 6/4/2024, with diagnoses including pressure-induced deep tissue damage (pressure ulcer - prolonged pressure to an area of skin and underlying tissue) of right heel, dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that the loss interferes with a person's daily life and activities), and lack of coordination (not able to move different parts of the body together well or easily). A review of the 'At Risk for Further Impaired Skin Integrity' Care Plan initiated 5/22/2024, indicated the focus was related to Resident 1's right heel deep tissue injury (DTI -purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from prolonged pressure and/or shear). The care plan interventions indicated to keep area dry and clean and to monitor / document / report changes in wound color, drainage, odor, sensation, or pain. The interventions also indicated to document the treatment weekly, including the measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (fluid that leaks out of blood vessels into nearby tissues) and any other notable changes or observations. A review of Resident 1's Minimum Data Set (MDS - a standardized resident assessment and care screening tool) dated 5/28/2024, indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn, remember and make decisions). The MDS indicated Resident 1 was dependent on facility staff for toilet hygiene, showering, and lower body dressing. The MDS indicated the resident was at risk for developing a pressure ulcer, had one or more unhealed pressure ulcers, and the resident was receiving treatment for one unstageable DTI (the stage of the wound is not clear, the base of wound is covered with tissue and pus that may be yellow, gray, green brown or black). A review of Resident 1's admission Assessment by the Treatment Nurse dated 6/4/2024, indicated the resident had a right heel DTI with 100% purple discoloration. The admission Assessment indicated there were no open areas noted and the resident had bilateral lower extremity hyperpigmentation (usually harmless skin condition that causes darker patches of skin than the surrounding area). The admission Assessment indicated wound care was rendered, well tolerated, and the resident denied pain. According to a review of the Physician's Order dated 6/5/2024, Resident 1 was to have treatment to the right heel DTI, cleanse with normal saline (a crystalloid fluid that was a mixture of water and salt) and pat dry. Apply betadine (topical antiseptic medication that contains povidone-iodine as the active ingredient), cover with abdominal (ABD) pad, and wrap with Kerlix (a brand of bandage rolls made from 100% woven gauze that could be used for wound care), every day shift for 21 days. A review of Resident 1's medical record and the Nursing Progress Notes dated from 6/4 - 6/20/2024 (16 days), indicated there was no documentation for the resident's right heel DTI regarding the color, drainage, odor, sensation, measurement including width, length, depth, and exudate (fluid that leaks out of blood vessels into nearby tissues), per the care plan. A review of Resident 1's medical record and Treatment Admin Record (TAR) dated June 2024 indicated there was no documentation including color, drainage, odor, sensation, measurement including width, length, depth, and exudate of Resident 1's right heel DTI. During an observation on 6/27/2024 at 10:49 AM, Licensed Vocational Nurse (LVN) 8 provided wound care to Resident 1 in the resident's room. Resident 1's right heel DTI was observed with no exudate and the resident did not show signs or symptoms of pain during the treatment. During a concurrent interview, LVN 8 stated she would document the treatment in the TAR, but LVN 8 did not document the description of the DTI. During a concurrent interview and record review on 6/27/2024 at 12:15 PM with the Director of Nursing (DON), Resident 1's 'At Risk for Further Impaired Skin Integrity' Care Plan was reviewed. The DON stated there was no documentation for the resident's weekly treatment to the right heel DTI, per the care plan interventions. The DON stated if there was no documentation, the facility would not know if the wound was improving or if the facility was providing the appropriate care to the resident. The DON stated this would cause a risk of infection or worsening of the wound. During a concurrent interview and record review on 6/27/2024 at 1:01 PM with LVN 8, Resident 1's Progress Notes were reviewed. LVN 8 stated there was no documentation for the resident's weekly treatment to the right heel DTI, per the care plan interventions, since the resident's re-admission. LVN 8 stated, if there was no documentation, that could potentially affect Resident 1's progress because the facility would not know if the wound was improving or if the treatment needed to be changed. LVN 8 stated Resident 1 could decline. A review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 1/18/2024, indicated the following information was to be documented in the resident medical record: objective observations; treatments or services performed; and progress toward or changes in the care plan goals and objectives. The P&P indicated documentation of procedures and treatments would include care-specific details, including: the date and time the procedure / treatment was provided; the assessment data and / or any unusual findings obtained during the procedure / treatment; and how the resident tolerated the procedure / treatment. A review of the facility's P&P titled, Wound Care, dated 1/18/2024, indicated the following information had to be recorded in the resident's medical record: the type of wound care given; the date and time the wound care was given; all assessment data (wound bed color, size, and drainage) obtained when inspecting the wound; and how the resident tolerated the procedure. A review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated March 2022, indicated assessment of the residents were ongoing and care plans were revised as information about the residents and the resident's condition changes. The P&P indicated the interdisciplinary team reviews and updates the care plan: when the resident had been readmitted to the facility from a hospital stay.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of six sampled residents (Resident 64), who had a history of falls, received services to prevent accidents and falls by failing to: -Implement the Risk for Falls Care Plan interventions dated 12/5/2023, including a yellow star on the wall above the headboard, a gold star on the name plate, a yellow fall risk wristband, yellow non-skid socks, and a yellow star on the wheelchair. -Revise and Update the Risk for Falls Care Plan after a fall on 2/16/2024. -Implement the facility's Falls and Fall Risk Managing policy to include a resident-centered fall prevention plan to reduce the specific risk factor of falls for Resident 64. These deficient practices caused an increased risk for falls and Resident 64's actual fall on 2/16/2024, which resulted in the resident's skin abrasion on the right anterior forearm (the main bone of the upper arms). Findings: A review of the admission Record indicated, Resident 64 was admitted to the facility on [DATE], with diagnoses including primary generalized osteoarthritis (a degenerative joint disease that worsens over time often resulting in chronic pain), difficulty in walking, pain in left knee, and history of falling. A review of the At Risk for Falls Care Plan revised 12/5/2023, related to generalized osteoarthritis, left knee pain, generalized weakness, and history of falling, indicated Resident 64 had a fall on 2/16/2024 (from the wheel chair). The care plan interventions included the facility falling star program: which included a yellow star on the wall above headboard, a gold star on name plate, a yellow fall risk wristband, a yellow non-skid sock, and a yellow star on wheelchair. A review of Resident 64's Change in Condition Evaluation (COC) form dated 2/16/2024, indicated Resident 64 had a fall and suffered a skin abrasion on the right anterior forearm (the main bone of the upper arms). A review of the Minimum Data Set (MDS-a comprehensive assessment and screening tool), dated 3/10/2024, indicated Resident 64 was cognitively intact, required substantial/maximal assistance with toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. A review of the Progress Notes dated 4/8/2024, indicated Resident 64 may have two floor mats to prevent injury in the event of a fall. During an observation on 5/8/2024 at 11:14 AM, Resident 64 was up in hallway sitting in wheelchair with two Restorative Nursing Assistants (RNAs). Resident 64 was observed without wearing the non-skid yellow socks, no fall risk wristband, or a yellow star on the wheelchair. Upon observation of Resident 64's room, there was no gold star on Resident 64 name plate, no fall mats observed and no yellow star above the wall on Resident 64's headboard, per the Falls Care Plan interventions. During an interview on 5/8/2024 at 12:35 PM, the Quality Assurance Nurse (QA Nurse) stated that all new admissions were placed on the falling star program for 72 hours. During a concurrent interview and record review on 5/8/2024 at 4 PM, with the Director of Nursing (DON), Resident 64's care plan, dated 12/2/2023 was reviewed. The DON stated Resident 64's care plan for at risk for falls and the falling star program should have been updated or revised after Resident 64's fall. The DON stated the care plan interventions should have been implemented including a yellow star on wall above headboard, a gold star on name plate, a yellow fall risk wristband, a yellow non-skid sock, and a yellow star on wheelchair. The DON stated that not having an updated care plan placed Resident 64 at increased risk for anther fall with injury. A review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, revised 3/2018, indicated the staff with the input of the attending physician will implement a resident-centered fall prevention plan to reduce the specific risk factor of falls for each resident at risk or with a history of falls, if a systemic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions. A review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised 7/2017 indicated assessments of residents were ongoing and care plans were revised as information about the residents' conditions change. The interdisciplinary team reviews and updates the care plan when there was a significant change in the residents' condition, and when the desired outcome was not met, or at least quarterly in conjunction with the required quarterly MDS assessment.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review, the facility failed to provide appropriate treatment and services for the resident's change in condition of loose stools for one of two sampled residents (Resident 74). Resident 74 continued to receive a laxative (medication used to treat constipation) and experience frequent loose stools without appropriate intervention. This deficient practice had the potential for Resident 74 to become dehydrated (a condition that occurs when you lose more fluid than you take in, not having enough water to carry out its normal functions) and potentially cause kidney damage, brain damage, and/or death. Findings: A review of Resident 74's admission Record indicated the facility admitted the resident on 3/16/2024 with diagnoses that included multiple myeloma (a rare blood cancer), moderate protein-calorie malnutrition (occurs when an individual does not eat enough protein and energy to meet their nutritional needs), Type II diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), dependence on renal dialysis (a type of treatment that helps your body remove extra fluid and waste products from the blood when the kidneys are not able to), difficulty in walking, and major depressive disorder (a persistent feeling of sadness and loss of interest that can interfere with daily activities of living). A review of the Physician's Order dated 3/16/2024 indicated the resident was to receive Polyethylene Glycol 3350 [MiraLAX, a laxative used to treat constipation) powder 17 grams by mouth every 12 hours for constipation. A review of Resident 74's History & Physical dated 3/18/2024, indicated the resident had the capacity to understand and make decisions. A review of Resident 74's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 3/23/2024, indicated the resident had severely impaired cognition (problems with a person's ability to think, remember, use judgement, and make decisions) and required substantial / maximal assistance for toileting hygiene and showering / bathing self. The MDS indicated Resident 74 was frequently incontinent of urine and bowel and there was no constipation present. According to a review of the March Medication Administration Record (MAR), Resident 74 received MiraLAX every 12 hours from 3/17 - 3/31/2024. A review of the March Documentation Survey Report (DSR) indicated Resident 74 had a large loose bowel movement on 3/18, 3/23, 3/24, 3/29, 3/30 and 3/31/2024. A review of the Nursing Progress Note dated 4/12/2024, indicated Certified Physician Assistant (PA-C) 1 assessed Resident 74 had constipation and that the resident was to receive MiraLAX. A review of the April MAR indicated Resident 74 received MiraLAX every 12 hours from 4/1/2024 - 4/30/2024. There was no documentation that indicated Resident 74's physician was notified the resident had loose bowel movements prior to 4/30/2024. A review of the April DSR indicated Resident 74 had a large loose bowel movement on 4/3, 4/4, 4/5, 4/23, 4/24, and two large loose bowel movements on 4/22/2024. The DSR indicated Resident 74 had a small loose bowel movement on 4/12, 4/13, 4/15, 4/21, 4/30 and two small loose bowel movements on 4/17 and 4/29/2024. This indicated Resident 74 had 13 loose bowel movements for the month of April. According to a review of Resident 74's Food and Nutrition Progress Note dated 4/29/2024, the facility Registered Dietitian (RD) spoke to the resident's dialysis RD who indicated Resident 74 had diarrhea and recommended a stool binder (medication that help control diarrhea). The Food and Nutrition Progress Note indicated the MiraLAX was not needed due to Resident 74's diarrhea. The progress note further indicated Resident 74 was not eating much due to the diarrhea. A review of Resident 74's Nursing Progress Note dated 4/30/2024, indicated the resident was seen by the RD with recommendations that included, as needed diarrhea mediation due to the resident complaining of diarrhea at the dialysis center. The progress note indicated Resident 74 was not able to be assessed at the time because the resident was out for an appointment. The progress note indicated the staff assigned to Resident 74 were interviewed, who indicated the resident did not complain of any diarrhea and had no episodes of diarrhea that day or the days prior. The progress note further indicated Resident 74's physician was aware and agreed with the recommendations. A review of Resident 74's Change in Condition (COC) Evaluation form dated 5/1/2024 at 11:20 AM, indicated the resident had another loose bowel movement and the vitals signs [measurements of the body's most basic functions which include: body temperature, heart rate, respiration (breathing) rate, blood pressure, and oxygen saturation (blood oxygen level)] were assessed to be within normal limits. The COC form indicated the resident's abdomen was soft with no distension (swollen outward) and no complaints of any pain during the diarrhea episodes. The Change of Condition Evaluation indicated Resident 74's physician personally checked the resident and provided new orders for Polyethylene Glycol 3350 powder 17 grams as needed. A review of the Physician's Order dated 5/1/2024, indicated Resident 74 was to receive Polyethylene Glycol 3350 powder 17 grams by mouth every 12 hours as needed for constipation. A review of Resident 74's MAR dated 5/1/2024 - 5/7/2024, indicated the resident stopped receiving MiraLAX every 12 hours and did not receive any as needed doses of MiraLAX from 5/1/2024 - 5/7/2024. According to a review of the May DSR, Resident 74 had a large loose bowel movement on 5/1, and a small loose bowel movement on 5/5 and 5/7/2024. During an interview on 5/7/2024 at 1:42 PM, Certified Nursing Assistant (CNA) 1 stated he had been working at the facility for 22 years, and Resident 74 was part of his permanent assignment. CNA 1 stated Resident 74 did not have diarrhea that day and stated the resident had a bowel movement once today and it was a regular bowel movement. CNA 1 stated Resident 74 had a lot of diarrhea last month, but could not remember the exact date. CNA 1 stated he notified the charge nurse but could not indicate who the charge nurse was. During an interview on 5/8/2024 at 6:51 AM, Resident 74 stated he gets diarrhea when he has chemotherapy and/or dialysis. Resident 74 stated the diarrhea was getting better and stated he was not having much anymore. Resident 74 stated he was feeling good with no pain. Resident 74 stated he was not sure if he was getting a laxative and that the nursing staff help him when he needs to get cleaned up after going to the bathroom. During an interview on 5/8/2024 at 3:31 PM, Licensed Vocational Nurse (LVN) 3 stated she was taking care of Resident 74 and there was no mention of Resident 74 having loose stools / diarrhea last month. LVN 3 stated Resident 74 had not had any diarrhea that day. LVN 3 stated Resident 74 was receiving MiraLAX twice a day, but indicated the orders for MiraLAX were changed to as needed. LVN 3 stated prior to giving a resident MiraLAX she would ask them if they were having diarrhea, loose stools, or any stomach pain. LVN 3 stated if the resident was having loose stools / diarrhea she would not give them MiraLAX because it was a laxative and would make the resident have more loose stools. On 5/9/2024 at 10 AM, during a concurrent interview and record review, Resident 74's MAR for 3/2024, 4/2024, and 5/2024 were reviewed with the Director of Nursing (DON). The DON stated Resident 74 was previously receiving MiraLAX twice a day and stated the order for MiraLAX was changed to as needed, because Resident 74 was complaining of diarrhea. Resident 74's DSR for 3/2024, 4/2024, and 5/2024 were reviewed with the DON. The DON stated the documentation on the reviewed DSRs indicated Resident 74 was in fact experiencing frequent loose stools and no documentation that Resident 74 was having hard stools. The DON stated when a resident had constipation their stools would be hard and they may have a hard time having a bowel movement. The DON stated when a resident had loose stools the stools could be a paste and would not be formed. The DON stated Resident 74 should not receive MiraLAX with loose stools and stated the resident's physician should have been notified of the loose stools sooner. The DON stated there was a risk for Resident 74 to become dehydrated if he received MiraLAX and continued to have loose stools/diarrhea. The DON stated MiraLAX is a laxative, which would make loose stools worse. During a telephone interview on 5/9/2024 at 10:44 AM, the RD stated when she spoke to the RD from the dialysis center on 4/29/2024, she was informed Resident 74 was having diarrhea. The RD stated it was the first time she was made aware Resident 74 was experiencing diarrhea. The RD stated Resident 74 was receiving chemotherapy and the resident's diarrhea could be coming from the chemotherapy. The RD stated Resident 74 did not need the MiraLAX because he was having diarrhea. The RD stated there was a risk of Resident 74 becoming dehydrated if he continued to have frequent loose stools and taking a laxative could make diarrhea worse. A review of the facility's policy and procedure titled,Change in a Resident's Condition or Status, revised 2/2021, indicated to promptly notify the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (changes in level of care, resident rights, etc.). The nurse would notify the resident's attending physician or physician on call when there has been a (an): accident or incident involving the resident; discovery of injuries of an unknown source; adverse reaction to medications; significant changes in the resident's physical/emotional/mental condition; need to alter the resident's medical treatment significantly; refusal of treatment or medications two (2) or more consecutive times; and / or specific instruction to notify the physician of changes in the resident's condition, except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. A review of the facility's undated policy and procedure titled, Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol, indicated as part of the initial assessment, the staff and physician will help identify individuals with previously identified lower gastrointestinal tract conditions and symptoms. This should include a review of gastrointestinal problems during any recent hospitalizations, results of previous barium studies, endoscopies, etc. The staff and physician will identify risk factors related to bowel dysfunction; for example, severe anxiety disorder, recent antibiotic use, or taking medications that are used to treat, or may cause or contribute to, gastrointestinal erosion, bleeding, diarrhea, dysmotility, etc. The staff an physician will monitor the individual's response to interventions and overall progress; for example, overall degree of comfort or distress, frequency and consistency of bowel movements, and the frequency, severity, and duration of abdominal pain etc. The physician will adjust interventions based on identification of causes, resident responses to treatment, and other relevant factors.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to provide necessary respiratory care services for one of three sampled residents (Resident 72) by failing to ensure Resident 72's nasal cannula (NC, device that gives you additional oxygen through your nose) tubing was labeled and stored in a plastic bag. This deficient practice had the potential for Resident 72 to experience complications associated with oxygen therapy, such as infection and respiratory distress. Findings: A review of Resident 72's admission Record indicated the facility initially admitted the resident on 2/12/2024 and re-admitted the resident on 4/29/2024 with diagnoses that included acute respiratory failure with hypoxia (a condition where you do not have enough oxygen in the tissues in your body), dependence on supplemental oxygen (treatment that provides you with extra oxygen to breath in), and cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area). A review of Resident 72's Oxygen Therapy care plan developed on 2/13/2024, indicated the resident had acute hypoxemic respiratory failure. The goal was to have no signs or symptoms of poor oxygen absorption. The care plan interventions indicated changing the residents position every two hours to facilitate lung secretion movement, give medications as ordered by the physician, and to monitor for signs and symptoms of respiratory distress. The care plan interventions further indicated Resident 72 was to receive oxygen at two liters per minute via NC to keep oxygen saturation (amount of oxygen present in the blood) above 93%, continuously. A review of Resident 72's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 2/19/2024, indicated the resident's cognitive skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated the resident was dependent on help for oral/toileting/personal hygiene, dressing, showering, and transfers. The MDS further indicated Resident 72 was receiving oxygen therapy. A review of Resident 72's Physician's Order dated 4/20/2024, indicated for the resident's oxygen tubing to be changed on Monday of every week during the night shift. A review of Resident 72's Physician's Order dated 4/29/2024, indicated for the resident to receive oxygen at two liters per minute via NC to keep oxygen saturation above 93%, continuously. During an observation on 5/6/2024 at 9:46 AM, in Resident 72's room, the resident's NC tubing was observed not labeled and hanging over the resident's tube feeding machine. During an observation on 5/7/2024 at 9:45 AM, in Resident 72's room, the resident's NC tubing was observed not labeled and placed inside the resident's bedside drawer. During a concurrent observation and interview, on 5/7/2024 at 9:59 AM, Licensed Vocational Nurse (LVN) 2 stated Resident 72's NC tubing should have been labeled with the date, otherwise the staff would not know how long the tubing was being used for. LVN 2 stated the resident's NC should not be inside the bedside drawer because Resident 72 could be at risk for infection if the NC was not stored properly. LVN 2 stated the NC should have been changed every week or as needed but should always be labeled and placed in a protective bag. During an interview on 5/7/2024 at 10:33 AM, Registered Nurse (RN) 1 stated the NC tubing should have been inside a plastic bag so the NC tubing would not get dirty and would not touch the floor. RN 1 stated the NC tubing should have been labeled and the tubing should have been changed once a week or as necessary. RN 1 stated Resident 72 could be at risk for infection if the NC tubing was exposed for more than seven days and not placed inside a bag. During an interview on 5/9/2024 at 4:54 PM, the Director of Nursing (DON) stated the NC tubing should have been inside a plastic bag and labeled with the date. The DON stated the NC tubing should have been changed every Monday or as needed. The DON stated Resident 72 was at risk for infection if the NC tubing was not labeled or inside a bag. A review of the facility's policy and procedures (P&P) titled, Departmental (Respiratory Therapy) - Prevention of Infection, reviewed 1/18/2024, indicated Infection Control Considerations Related to Oxygen Administration: Change the oxygen cannula and tubing every seven (7) days, or as needed and keep the oxygen cannula and tubing used as needed in a plastic bag when not in use.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide documented justification for the continuation of an antidepressant medication Effexor (a medication used to treat major depressive disorder, anxiety, and panic disorder) beyond 30 days for one of six sampled residents (Resident 64). This deficient practice had the potential to cause Resident 64 to receive an unnecessary medication that can lead to adverse side effects. Findings: A review of the admission Record indicated Resident 64 was admitted to the facility on [DATE], with diagnoses that included major depressive disorder, recurrent and unspecified (constant loss of interest in daily activities or things once liked), primary generalized osteoarthritis (a degenerative joint disease that worsens over time often resulting in chronic pain), difficulty in walking, and pain in left knee. A review of the Mood Disturbance Care Plan related to diagnosis of depression, manifested by verbalization of sadness was 12/4/2023. The goal indicated Resident 64 would be free of signs and symptoms of depression, anxiety, or sad mood by the review date, but no review date was indicated. The care plan interventions indicated to administer medications as ordered and monitor for side effects and effectiveness, arrange for a psych consult, follow up as indicated, assess, record, and report signs and symptoms of depression to doctor including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing negative statements, repetitive anxious or health-related complaints, and tearfulness. A review of the Physician's Order Summary Report, dated 12/4/2023, indicated Resident 64 was to receive Effexor extended release (XR) oral capsule 150 MG (a unit of measurement of mass metric system) one time a day for depression, manifested by verbalization of sadness. According to a review of the Medication Administration Record (MAR), dated from 12/4/2023 - 3/9/2024, Resident 64 received Effexor (XR) 150 MG daily and there were no episodes of the resident's verbalization of sadness. A review of the Consultant Pharmacist's Medication Regimen Review (MRR), dated 1/1/2024 through 3/9/2024 indicated no recommendations, actions, or rationale for the daily administration of Effexor HCL XR 150 MG. A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated 3/10/2024, indicated Resident 64 was cognitively intact (able to make decisions) and required substantial/maximal assistance with toileting hygiene, shower/bathe self, lower body dressing, and putting on and taking off footwear. A review of the Consultant Pharmacist MRR dated from 3/10/2023 - 4/30/2024 indicated for Resident 64 there were no recommendations, actions, or rationale (a set of reasons for actions) for the daily administration of Effexor HCL XR 150 MG. According to a review of the facility's Psychotropic and Sedative/Hypnotic Utilization by Resident form, dated 4/30/2024, Resident 64 was receiving Effexor HCL 150 MG daily for depression manifested by verbalization of sadness and the next evaluation was 6/1/2024. A review of the MAR dated from 3/10/2023 through 5/8/2024 indicated Resident 64 had no behavior episodes of verbalization of sadness while taking Effexor XR 150 MG daily. During a concurrent interview and record review on 5/8/2024 at 3:36 PM with Director of Nurses (DON), the facility's policy and procedure (P&P) titled, Medication Regimen Reviews, revised 5/2019 was reviewed. The policy indicated the consultant pharmacist reviews the medication regimen of each resident at least monthly. The consultant pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication. The consultant pharmacist provides a written report to the attending physicians for each resident identified as having a non-life-threatening medication irregularity. The report contains: resident's name, medication, identified irregularity, and the pharmacist recommendation. The DON stated, there was no documentation of a Gradual Dose Reduction (GDR) for Resident 64. The DON stated it was important to have a GDR to make sure the resident needs the medications they were prescribed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for one of four sampled residents (Resident 78) by not having the medication Megestrol Acetate Oral Suspension (a medication available as mixture where solid particles do not dissolve completely in a liquid solution, used to stimulate appetite increasing the feeling to have more food) available for administration for 17 days. This failure resulted in significant weight loss for Resident 78 and had the potential to result in malnutrition and hospitalization. Findings: A review of Resident 78's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including intracranial (within the skull) abscess (a pocket of pus) and granuloma (a cluster of white blood cells and tissue due to infection), hearing loss, pressure-induced deep tissue damage of sacral region, and gastroesophageal reflux disease (GERD - a short medical term for a condition when stomach acid flows back into esophagus [the tube connecting mouth and stomach]) without esophagitis (inflammation of esophagus). A review of Resident 78's History and Physical, dated 4/3/2024, indicated resident had the capacity to understand and make decisions. A review of the weight records dated 4/3/2024 indicated Resident 78 weighed 165 pounds. According to a review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 4/8/2024, Resident 78 had intact cognition (ability to understand and make decisions) and was dependent on the facility staff for moderate to maximal assistance for activities of daily living (ADL - tasks of everyday life that include personal and oral hygiene, toileting, showering, and dressing). A review of Resident 78's Mini Nutrition Evaluation, dated 4/10/2024, indicated a score of 10 indicating the resident was at risk for malnutrition. A review of the Unplanned Weight Loss care plan dated 4/17/2024, and the Risk for Poor PO (by mouth) Intake care plan dated 4/19/2024, indicated the facility interventions were to administer medication as ordered, megestrol acetate oral suspension 400 mg/10 mL, give 10 mL by mouth one time a day for appetite stimulant. A review of the Physician's Order Summary Report dated 4/20/2024, indicated Resident 78 was to receive Megestrol Acetate Oral Suspension (a mixture where solid particles do not dissolve completely in a liquid solution) 400 milligrams (mg - a unit of measurement) / 10 milliliter (mL - a unit of measurement), give 10 mL by mouth one time a day for appetite stimulant. During the medication pass observation on 5/7/2024 at 9:48 AM, Licensed Vocational Nurse (LVN) 1 prepared to administer the medications for Resident 78. LVN 1 did not have the Megestrol Acetate Oral Suspension in the medication cart (Med Cart Station 2). During a concurrent interview, LVN 1 stated Resident 78's Megestrol Acetate suspension was not available to administer to the resident. LVN 1 stated if the medication was not available to administer, code 9 was entered with notes explaining why the medication was not administered. LVN 1 stated Megestrol was previously administered on 5/6/2024. During a medication reconciliation review on 5/7/2024 at 12:16 PM, Resident 78's current physician's orders dated 4/30/2024 and Medication Administration Record (MAR - log of all medications given to resident)) for the month of May 2024 were reviewed. Resident 78's MAR indicated the Megestrol scheduled at 9 AM daily, was marked as administered on 5/7/2024, even though the medication was not available in stock. During a concurrent interview and record review on 5/7/2024 at 12:23 PM with LVN 1, the MAR and the Administration Detail for 5/7/2024 were reviewed. LVN 1 stated she inaccurately marked Megestrol Acetate as administered at 10:10 AM by mistake, when the medication was not in stock to be administered. LVN 1 stated this inaccurate representation of administration record would fail to treat Resident 78 and could lead to significant weight loss if he missed multiple doses of Megestrol. LVN 1 stated Resident 78 would experience body weakness and problems with performing activities of daily living if the resident was losing weight and did not receive the appetite stimulant as ordered. A review of Resident 78's MAR dated from 4/1/2024 to 5/7/2024, indicated documentation that the resident was administered 18 doses of Megestrol Acetate Suspension by nine different licensed nurses, when the medication was not available in stock. A review of the weight records dated 5/7/2024 indicated Resident 78 weighed 156 pounds, which was more than a five percent weight loss in one month. A review of facility's document titled,Rx Delivery Receipt, (a pharmacy document indicating pharmacy deliveries to the facility) dated 5/7/2024, indicated Megestrol Acet 40 mg/mL Susp 1 package of quantity 240 was delivered to facility for Resident 78 on 5/7/2024 at 12:52 PM. During an interview on 5/8/2024 at 10:07 AM, the Director of Nursing (DON), stated Resident 78's Megestrol Acetate was to improve the resident's appetite and help him eat better. The DON stated if a medication was not available, the facility staff was supposed to document code 9, inform the physician and request pharmacy if there were any alternatives. The DON stated if there was a mistake of documentation, it can be stroked out with a progress note to indicate that there was an error in documentation. The DON stated she did not have documentation of the pharmacy delivery for Megestrol prior to 5/7/2024 and that all LVNs were aware that documentation on administered medications should only happen after they were administered. The DON stated she did not know why the Megestrol doses were marked as administered in absence of the medication being in stock. The DON stated Resident 78 would start to feel weak, dizzy and if continued to lose weight then there would be a risk for hospitalization if the resident did not eat because of not receiving the ordered medication. During a telephone interview on 5/8/2024 at 1:47 PM, the Registered Pharmacist (RPH) stated Megestrol Acetate was requested by the facility on 4/19/2024 but was not delivered to the facility. The RPH stated Megestrol for Resident 78 was recently delivered to facility on 5/7/2024. During an interview on 5/8/2024 at 3:01 PM, LVN 3 stated the initials on the MAR were her initials but did not recall if she did or did not have the medication for the resident. LVN 3 stated if the medication was documented as given on the MAR, but not actually administered, that was inaccurate. LVN 3 stated not receiving the medication as ordered would cause the resident to not be able to eat well, lose weight, would be unable to do normal ADLs, potentially become hypoglycemic and would not heal to be able to fight infections. During an interview on 5/9/2024 at 10:44 AM, Resident 78's Representative (RR) stated the resident had not been eating well because nothing tastes good to him. The RR stated she remembered Resident 78's weight on 3/5/2024 to be 182 pounds, which reduced to 156 pounds on 5/9/2024. On 5/9/2024 at 11:09 AM, during an interview, Resident 78 stated he was given one drink which was a brown colored drink. Resident 78 stated he had not received a white colored Megestrol drink until the day before on 5/8/2024. During an interview on 5/9/2024 at 12:50 PM, the Medical Director (MD) stated Resident 78 was not his patient, but the facility requested for a second opinion to reevaluate the care. The MD stated Resident 78 was losing weight, not gaining weight, and that he was not aware of the false documentation of the medication administration. The MD stated Resident 78 refused Megestrol on 5/8/2024 and complained about not sleeping well so the MD prescribed a different medication to treat the weight loss and possible depression. During an interview on 5/9/2024 at 3:43 PM, the Registered Dietician (RD) stated she remembered speaking with Resident 78 on 4/17/2024 but did not document anything because there were no complaints. The RD stated, Resident 78's PO intake was good at 50-100% based on how nurses documented. We gave him appetite stimulant Megace around second or third week of April. His PO became more stable at 50-75% consistently for all meals. The RD stated Resident 78 was on antibiotics and healing from a wound, which was why he was losing weight. The RD stated there was a note on 5/8/2024 of significant weight loss because antibiotics cause appetite loss. The RD stated if Resident 78 continued to lose weight, he would not heal, and infection would potentially recur and place resident at risk for being malnourished. A review of the facility's P&P titled, Pharmacy Services Overview, undated, indicated nursing staff communicate prescriber orders to the pharmacy and were responsible for contacting the pharmacy if a resident's medication was not available for administration. Borrowing medications from other residents or from the emergency medication supply because of a failure to order or reorder a medication was not acceptable practice. The policy indicated medications were received, administered and disposed of according to all applicable state and federal laws. A review of the facility's P&P titled, Administering Medications, dated April 2019 indicated medications were administered in accordance with prescriber orders, including any required time frame. A review of the facility's P&P titled, Documentation of Medication Administration, dated April 2007, indicated administration of medication must be documented immediately after (never before) it was given. Documentation must include, as a minimum, date and time of administration, reason (s) why a medication was withheld, not administered, or refused.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure safe storage of a bottle of Dorzolamide-Timolol Ophthalmic Solution (a medication in the form of eye drops with a combination of two medications used for treatment of high pressure in the eyes), according to the manufacturer's requirements affecting Resident 7 in one of two medication room refrigerators inspected (Medication Room Station 1). This failure to store medications per the manufacturers' requirements increased the risk that Resident 7 could have received medication that had become ineffective or toxic due to improper storage possibly leading to eye complications or hospitalization. Findings: During a concurrent observation and interview on 5/7/2024 at 4:05 PM of Station 1 Medication Room Refrigerator, with Licensed Vocational Nurse (LVN) 7, the following medication was found in the refrigerator at 40-degree Fahrenheit (F - a unit of measurement for temperature) not stored in accordance with manufacturer's requirements: -One bottle of Dorzolamide-Timolol 22.3 milligrams (mg - a unit of measurement) / 6.8 mg per milliliter (mL - a unit of measurement) Ophthalmic Solution for Resident 7. According to the manufacturer's product labeling, Dorzolamide-Timolol should be stored between 68-degree F to 77-degree F. LVN 7 stated Dorzolamide-Timolol eye drops should not be in the refrigerator. LVN 7 stated she would call the pharmacy to inform them and request replacement. LVN 7 stated this inappropriate storage of eye drops could make the medication ineffective and would not improve resident's eye condition. During an interview on 5/8/2024 at 10:32 AM, the Director of Nursing (DON) stated Dorzolamide -Timolol ophthalmic solution should not have been stored in the refrigerator. The DON stated the eye drops would not be effective to treat the elevated eye pressure and had the risk of causing eye irritation, redness, and other eye complications for Resident 7 because it was not stored in accordance with manufacturer's guidelines. A review of the facility's policy and procedure (P&P) titled, Storage of Medications, dated April 2019, indicated drugs and biologicals used in the facility were stored in locked compartments under proper temperature, light and humidity controls.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the resident's needs for one of four sampled residents (Resident 78). Resident 78, who was at risk for malnutrition, did not receive 17 doses of Megestrol Acetate Suspension medication (used to stimulate appetite, increasing the feeling to have more food) during medication administration, per physician's order. The facility also failed to maintain accurate medication administration records, per facility's policies and procedures (P&P) titled, Administering Medications, the policy Documentation of Medication Administration, and the policy Pharmacy Services Overview. As a result, Resident 78 had significant weight loss with the potential for malnutrition and hospitalization. Findings: A review of Resident 78's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including intracranial (within the skull) abscess (a pocket of pus) and granuloma (a cluster of white blood cells and tissue due to infection), hearing loss, pressure-induced deep tissue damage of sacral region, and gastroesophageal reflux disease (GERD - a short medical term for a condition when stomach acid flows back into esophagus [the tube connecting mouth and stomach]) without esophagitis (inflammation of esophagus). A review of Resident 78's History and Physical, dated 4/3/2024, indicated resident had the capacity to understand and make decisions. A review of the weight records dated 4/3/2024 indicated Resident 78 weighed 165 pounds. According to a review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 4/8/2024, Resident 78 had intact cognition (ability to understand and make decisions) and was dependent on the facility staff for moderate to maximal assistance for activities of daily living (ADL - tasks of everyday life that include personal and oral hygiene, toileting, showering, and dressing). A review of Resident 78's Mini Nutrition Evaluation, dated 4/10/2024, indicated a score of 10 indicating the resident was at risk for malnutrition. A review of the Unplanned Weight Loss care plan dated 4/17/2024, and the Risk for Poor PO (by mouth) Intake care plan dated 4/19/2024, indicated the facility interventions were to administer medication as ordered, megestrol acetate oral suspension 400 mg/10 mL, give 10 mL by mouth one time a day for appetite stimulant. A review of the Physician's Order Summary Report dated 4/20/2024, indicated Resident 78 was to receive Megestrol Acetate Oral Suspension (a mixture where solid particles do not dissolve completely in a liquid solution) 400 milligrams (mg - a unit of measurement) / 10 milliliter (mL - a unit of measurement), give 10 mL by mouth one time a day for appetite stimulant. During the medication pass observation on 5/7/2024 at 9:48 AM, Licensed Vocational Nurse (LVN) 1 prepared to administer the medications for Resident 78. LVN 1 did not have the Megestrol Acetate Oral Suspension in the medication cart (Med Cart Station 2). During a concurrent interview, LVN 1 stated Resident 78's Megestrol Acetate suspension was not available to administer to the resident. LVN 1 stated if the medication was not available to administer, code 9 was entered with notes explaining why the medication was not administered. LVN 1 stated Megestrol was previously administered on 5/6/2024. During a medication reconciliation review on 5/7/2024 at 12:16 PM, Resident 78's current physician's orders dated 4/30/2024 and Medication Administration Record (MAR - log of all medications given to resident)) for the month of May 2024 were reviewed. Resident 78's MAR indicated the Megestrol scheduled at 9 AM daily, was marked as administered on 5/7/2024, even though the medication was not available in stock. During a concurrent interview and record review on 5/7/2024 at 12:23 PM with LVN 1, the MAR and the Administration Detail for 5/7/2024 were reviewed. LVN 1 stated she inaccurately marked Megestrol Acetate as administered at 10:10 AM by mistake, when the medication was not in stock to be administered. LVN 1 stated this inaccurate representation of administration record would fail to treat Resident 78 and could lead to significant weight loss if he missed multiple doses of Megestrol. LVN 1 stated Resident 78 would experience body weakness and problems with performing activities of daily living if the resident was losing weight and did not receive the appetite stimulant as ordered. A review of Resident 78's MAR dated from 4/1/2024 to 5/7/2024, indicated documentation that the resident was administered 18 doses of Megestrol Acetate Suspension by nine different licensed nurses, when the medication was not available in stock. A review of the weight records dated 5/7/2024 indicated Resident 78 weighed 156 pounds, which was more than a five percent weight loss in one month. A review of facility's document titled,Rx Delivery Receipt, (a pharmacy document indicating pharmacy deliveries to the facility) dated 5/7/2024, indicated Megestrol Acet 40 mg/mL Susp 1 package of quantity 240 was delivered to facility for Resident 78 on 5/7/2024 at 12:52 PM. During an interview on 5/8/2024 at 10:07 AM, the Director of Nursing (DON), stated Resident 78's Megestrol Acetate was to improve the resident's appetite and help him eat better. The DON stated if a medication was not available, the facility staff was supposed to document code 9, inform the physician and request pharmacy if there were any alternatives. The DON stated if there was a mistake of documentation, it can be stroked out with a progress note to indicate that there was an error in documentation. The DON stated she did not have documentation of the pharmacy delivery for Megestrol prior to 5/7/2024 and that all LVNs were aware that documentation on administered medications should only happen after they were administered. The DON stated she did not know why the Megestrol doses were marked as administered in absence of the medication being in stock. The DON stated Resident 78 would start to feel weak, dizzy and if continued to lose weight then there would be a risk for hospitalization if the resident did not eat because of not receiving the ordered medication. During a telephone interview on 5/8/2024 at 1:47 PM, the Registered Pharmacist (RPH) stated Megestrol Acetate was requested by the facility on 4/19/2024 but was not delivered to the facility. The RPH stated Megestrol for Resident 78 was recently delivered to facility on 5/7/2024. During an interview on 5/8/2024 at 3:01 PM, LVN 3 stated the initials on the MAR were her initials but did not recall if she did or did not have the medication for the resident. LVN 3 stated if the medication was documented as given on the MAR, but not actually administered, that was inaccurate. LVN 3 stated not receiving the medication as ordered would cause the resident to not be able to eat well, lose weight, would be unable to do normal ADLs, potentially become hypoglycemic and would not heal to be able to fight infections. During an interview on 5/9/2024 at 10:44 AM, Resident 78's Representative (RR) stated the resident had not been eating well because nothing tastes good to him. The RR stated she remembered Resident 78's weight on 3/5/2024 to be 182 pounds, which reduced to 156 pounds on 5/9/2024. On 5/9/2024 at 11:09 AM, during an interview, Resident 78 stated he was given one drink which was a brown colored drink. Resident 78 stated he had not received a white colored Megestrol drink until the day before on 5/8/2024. During an interview on 5/9/2024 at 12:50 PM, the Medical Director (MD) stated Resident 78 was not his patient, but the facility requested for a second opinion to reevaluate the care. The MD stated Resident 78 was losing weight, not gaining weight, and that he was not aware of the false documentation of the medication administration. The MD stated Resident 78 refused Megestrol on 5/8/2024 and complained about not sleeping well so the MD prescribed a different medication to treat the weight loss and possible depression. During an interview on 5/9/2024 at 3:43 PM, the Registered Dietician (RD) stated she remembered speaking with Resident 78 on 4/17/2024 but did not document anything because there were no complaints. The RD stated, Resident 78's PO intake was good at 50-100% based on how nurses documented. We gave him appetite stimulant Megace around second or third week of April. His PO became more stable at 50-75% consistently for all meals. The RD stated Resident 78 was on antibiotics and healing from a wound, which was why he was losing weight. The RD stated there was a note on 5/8/2024 of significant weight loss because antibiotics cause appetite loss. The RD stated if Resident 78 continued to lose weight, he would not heal, and infection would potentially recur and place resident at risk for being malnourished. A review of the facility's P&P titled, Pharmacy Services Overview, undated, indicated nursing staff communicate prescriber orders to the pharmacy and were responsible for contacting the pharmacy if a resident's medication was not available for administration. Borrowing medications from other residents or from the emergency medication supply because of a failure to order or reorder a medication was not acceptable practice. The policy indicated medications were received, administered and disposed of according to all applicable state and federal laws. A review of the facility's P&P titled, Administering Medications, dated April 2019 indicated medications were administered in accordance with prescriber orders, including any required time frame. A review of the facility's P&P titled, Documentation of Medication Administration, dated April 2007, indicated administration of medication must be documented immediately after (never before) it was given. Documentation must include, as a minimum, date and time of administration, reason (s) why a medication was withheld, not administered, or refused (as applicable).

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure food stored in the kitchen were dated and labeled. This deficient practice had the potential to cause food-borne illnesses for all residents who receive food from the kitchen. Findings: During the initial kitchen tour on 5/6/2024 at 8:10 AM, the following items were observed unlabeled and undated in the walk in refrigerator: -two bags of unopened whole wheat bread loaves, -one opened bag of whole wheat bread, -one opened bag of hamburger buns, -seven bags of frozen broccoli, -13 bags of frozen spinach, 10 bags of frozen mixed vegetables, -4 bags of frozen peas, 5 bags of frozen carrots, and 2 bags of cauliflower. During a concurrent interview, the Dietary [NAME] (DC) stated the opened and unopened bags of bread were undated and unlabeled. The DC stated the bags of frozen vegetables were undated and unlabeled. The DC stated all food stored in the kitchen should be labeled and dated to know how long the food was good for. The DC stated all food should be dated and labeled to prevent food-borne illness. During an interview on 5/9/2024 at 10:20 AM, the Director of Nurses (DON) stated all food stored in the kitchen should be labeled and dated to ensure kitchen staff know which foods were safe for the residents to eat and prevent food-borne illness. A review of the facility's policy and procedure titled, Labeling and Dating of Foods, dated 2023, indicated all food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Food delivered to facility needs to be marked with a received date. Note that the delivery sticker is dated, and it can serve as the delivery date for the product. Newly opened food items will need to be closed and labeled with an open date and used by the date that follow the various storage guidelines within this section-specifically the Dry Goods Storage Guidelines (page 6.9), Refrigerated Storage guidelines (page 6.16), Produce Storage Guidelines (page 6.18), and Freezer Storage Guidelines (page 6.20).

Apr 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the transfer records from the general acute hospital (GACH 1) were reviewed thoroughly for one of two sampled residents (Resident 1). For Resident 1, who had appointments arranged by the general acute hospital (GACH 1) for vascular diagnostic (a test used to determine possible circulation problems of the blood vessels), chemotherapy (use of drugs to destroy cancer cells), hematologist (medical doctor who had special training in diagnosis and treating blood disorders) and pulmonologist (medical doctor who had special training in diagnosing and treating diseases of the lungs (body organ that helps with breathing) prior to Resident 1's transfer and admission to the facility on 3/16/24, the facility failed to: 1. Thoroughly review Resident 1's GACH 1 transfer record when the facility admitted Resident 1 on 3/16/24. 2. Notify Resident 1's physician about Resident 1's appointments arranged by the GACH 1 to make decisions whether to continue with the treatment and diagnostics. These deficient practices resulted in delay of treatment for Resident 1 due to the missed appointments on 3/18/24, 3/21/24, 3/26/24, 3/28/24, 4/2/24, 4/10/24, 4/11/24, 4/18/24 and 4/25/24. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 3/16/24 with diagnoses including multiple myeloma (blood cancer that develops in the plasma cells (white blood cells that protect the body form infection), anemia and difficulty in walking. During a review of the Minimum Data Set (MDS, standardized care and health screening tool) dated 3/23/24 indicated Resident 1 had impaired cognition (ability to think and reason). Resident 1 needed substantial assistance (helper does more than half the effort) with putting on/taking off footwear, lower body dressing, shower, toileting hygiene, moderate assistance (helper does less than half the effort) with upper body dressing, oral hygiene, and supervision with eating. During a review of the GACH 1 Inpatient Progress Note dated 3/15/24 indicated Resident 1 had follow-up appointments as follows: 1. Vascular diagnostic on 3/18/24 at 1 p.m.; 2. Vascular diagnostic on 3/21/24 at 1 p.m.; 3. Infusion chemotherapy for three hours on 3/21/24 at 2 p.m.; 4. Vascular Surgery return on 3/26/24 at 8:30 a.m.; 5. Adult primary care on 3/26/24 at 10:20 a.m.; 6. Infusion chemotherapy for 5 hours on 3/28/24 at 8:30 a.m.; 7. Hematologist on 4/2/24 at 1:30 p.m.; 8. Pulmonologist on 4/10/24 at 2:45 p.m.; 9. Infusion chemotherapy for five hours on 4/11/24 at 8:30 am.; 10. Infusion chemotherapy for three hours on 4/18/24 at 9 am; 11. Infusion chemotherapy for five hours on 4/25/24 at 8:30 am.; 12. Infusion chemotherapy for five hours on 5/9/24 at 8:30 a.m.; 13. Infusion chemotherapy for three hours on 5/16/24 at 9 a.m. and 14. Infusion chemotherapy for five hours on 5/23/24 at 8:30 a.m. During an interview and concurrent review on 4/23/24 at 1:27 p.m., Resident 1's GACH 1 Inpatient Progress Note was reviewed with the director of nursing (DON). During concurrent interview, the DON stated the GACH 1 called the facility and gave report about Resident 1 prior to admission on [DATE]. DON stated GACH 1 did not inform the facility that Resident 1 had appointments. DON stated the registered nurse (RNS) that admitted Resident 1 did not review the inpatient progress notes that had Resident 1's appointments but used the other pages with medications to transcribe the admission orders and verify with Resident 1's primary physician. During an interview on 4/25/24 at 3:48 p.m., RNS 1 stated GACH 1 records should be reviewed on admission to find out what is relevant such as allergies, diagnoses, and appointments. RNS 1 stated if there are appointments the social services will be notified to set up the transportation. During a review of the facility Policy titled Charting and Documentation reviewed on 1/18/24 indicated documentation in the medical record will be objective (not opinionated or speculative) complete and accurate. During a review of the facility Policy titled admission reviewed on 1/18/24 indicated preliminary resident information shall be documented upon a resident's admission to the facility. The same Policy indicated this initial information-gathering precedes the complete history and physical assessment that also accompanies the resident admission process. During a review of the facility Policy titled Resident Rights reviewed on 1/18/24 indicated the resident has the right for communication with and access to people and services, both inside and outside the facility.

Mar 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0567 (Tag F0567)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to safeguard personal funds for one of three sampled residents (Resident 1). The Licensed Vocational Nurse (LVN) 1 retrieved $800 from Resident 1 and placed the money in the narcotic box. This failure had the potential to result in Resident 1's personal funds becoming stolen or misused. Findings: A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including heart failure, unspecified (occurs when the heart muscle does not pump blood as well as it should), Type II diabetes mellitus with other skin ulcer (a complication caused by poor circulation and nerve damage from high blood sugar levels), and essential hypertension (elevated blood pressure without a known cause). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 3/18/2024, indicated Resident 1 was cognitively intact, was dependent and or required maximum assistance from staff with dressing, toilet use and personal hygiene. A review of Resident 1's Inventory of Personal Effects dated 3/28/2024 (after a re-admission) indicated Resident 1 was admitted with $900.00 cash. $100 remained in Resident 1's wallet and $800 was stored inside the facility medication cart by staff. During an interview on 3/29/2024 at 12:52 PM, LVN 1 stated Resident 1 gave him $900 on 3/27/2024 and requested to keep $100. LVN 1 informed Resident 1 of the facility's process to keep the $800 in the narcotic box until Social Services arrived. During a concurrent interview, the Social Services staff stated she saw Resident 1's inventory of $800 on 3/28/2024 kept inside the medication cart. SS stated, the money belonging to Resident 1 was removed on 3/29/2024 (two days later) by social service assistant and the Administrator. SS stated the money should have been removed the following business day 3/28/2024 and placed with business office. During an interview on 4/9/2024 at 3:50 PM, the Administrator (Admin) stated Resident 1's money was supposed to be in the business office on the next available business day, until the resident request for it. The Admin stated the transaction required two signatures; the nurse in charge would sign and a business office personnel would co-sign. The retrieved money would be placed in the business office to safeguard. A review of the facility's policy and procedure titled, Management of Residents' Personal Funds, revised 4/2017, indicated the resident may have the facility hold, safeguard, and manage his or her personal funds. Should the facility manage the resident's funds, the facility will act as a fiduciary (someone who manages money or property for someone else) of the resident funds. Should the resident elect to have the facility manage his or her personal funds, it must be authorized in writing, by the resident or the resident's representative, and a copy of such authorization must be documented in the resident's medical record. Inquires concerning the facilities management of resident funds should be referred to the Administrator or to the business office.

Nov 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from verbal abuse. This failure had the potential to result in mental anguish, depression, anxiety and has the potential to result in physical abuse. Findings: A review of Resident 1 ' s admission record, indicated Resident 1 was admitted to the facility on [DATE] with a diagnoses including assault by unspecified firearm discharge, essential hypertension (high blood pressure that is multifactorial and doesn ' t have one distinct cause), and unsteadiness on feet (not walking in a steady way). A review of Resident 1 ' s history and physical dated 3/2/2023 indicated Resident 1 had the capacity to understand and to make decisions. A review of Resident 1 ' s Minimum Data Set [MDS- a comprehensive assessment and care screening tool] dated 9/9/2023, indicated the resident was cognitively intact, and required limited assistance with activities of daily Living [ADL ' s- activities related to personal care]. During an interview on 11/21/23, at 9:17 a.m., Resident 1 stated he informed CNA 2 that his roommate needed to be changed. CNA 2 then had an attitude with Resident 1. Resident 1 stated CNA 2 got angry and started an argument with Resident 1. Resident 1 stated CNA 2 stated to him, Whoever the person that shot you, did not do a good job. Resident 1 stated, That hurt my feelings and made me very angry. Resident 1 stated that was when Resident 1 and CNA 2 started exchanging words. Resident 1 stated he was tired of smelling Residents A and C ' s dirty diapers all night. Resident 1 stated he witnessed CNA 2 arguing with other nurses but cannot remember the date or the name of the nurses. Resident 1 stated he did not fear remaining in the facility. Resident 1 stated he did not want CNA 2 to come back into his room. Resident 1 stated he had never been physically abused by any of the staff or another resident. Resident 1 stated the staff treat him with dignity and respect and it was a misunderstanding and did not wish for any discipline to happen to CNA 2. Resident 1 stated he refused to see a psychiatrist because he did not need to see one because of a misunderstanding with CNA 2. Resident 1 stated, This alleged abuse has not changed the way that I go about my day. During an interview on 11/21/23, at 10:57 a.m., the Social Services Director (SSD) stated she had been employed with the facility for five months and was fully vaccinated. The SSD stated the Interdisciplinary (IDT) meeting for Resident 1 was done post incident. The SSD stated the alleged abuse was reported to her by the Director of Nursing (DON) that Resident 1 threatened to beat up CNA 2. The IDT meeting took place on 11/15/2023 at around 2 PM with Resident 1 regarding an alleged verbal aggression with staff member that occurred on 11/14/2023 at around 3 AM., that CNA 2 reported to the charge nurse alleging Resident 1 threatened her verbally. The SSD stated during the IDT meeting Resident 1 stated he did not threaten CNA 2, but they had an argument and CNA 2 stated, I don't know who shot you, but they did not do a good job. Resident 1 stated he was not bothered nor affected by the claim. Therefore, did not feel the need to report to any staff. The first time reporting the claim per resident, was during IDT. The SSD stated Resident 1 had not had any problems with any of the staff since being admitted to the facility. The SSD stated during the interview with Resident 1 he did not verbalize fear remaining in the facility. The SSD stated Resident 1 stated he was ok and did not wish to press any charges against CNA 2. During an interview on 11/21/23, at 2:05 p.m., LVN 2 (11-7 charge nurse) stated at approximately 2:30 a.m. he heard CNA 2 say something to Resident 1, but he was not sure what she said to Resident 1, as he was coming from the vending machine and Resident 1 started yelling and cursing at CNA 2. LVN 2 stated he intervened and asked Resident 1 what happened, and Resident 1 refused to talk about what transpired between him and CNA 2 prior to this incident. LVN 2 stated Resident 1 stated CNA 2 left his roommate wet and soiled with feces smelling up the room, and all he asked her to do was change both of his roommates on a regular basis, so that the room was not smelling. CNA 2 became mad and started yelling and cursing at him telling him not to tell her how to do her job. LVN 2 stated CNA 2 did not report any prior incidents to him about any arguments or any threats from Resident 1. LVN 2 stated Resident 1 was very nice and quiet. LVN 2 stated he had never witnessed Resident 1 verbally or physically abuse any of the staff. A review of the facility policy and procedure titled, Abuse and Neglect-Clinical Protocol, with a revised date of 11/9/2023, indicated willful as defined and used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Jun 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to supervise and prevent one of three sampled residents (Resident 1), who was cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and unable to make decisions, from eloping (unsupervised wandering that leads to a resident leaving a facility without permission or staff knowledge) from the facility, as evidenced by: 1. Resident 1 leaving the facility unaccompanied on 6/13/2023. 2. Evening shift staff being unable to find Resident 1 upon search of the facility ' s premises and vicinity. 3. The Director of Nursing (DON) and Infection Preventionist (IP) locating Resident 1 on 6/14/2023 sitting outside on the front porch of the Resident ' s previous address, approximately 9 miles from the facility. These deficient practices had the potential to result in the harm or death of Resident 1. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 3/6/2023 with diagnoses including nontraumatic acute subdural hemorrhage (a sudden bleeding that occurs between the space of the brain and the skull), interstitial pulmonary disease (a disease that causes scarring of lung tissue that makes it difficult to breathe), abnormalities of gait and mobility (not being able to walk or move normally), cognitive communication deficit (difficulty with thinking and how to use language), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and a history of falling. A review of Resident 1 ' s Care Plan initiated 3/6/2023, indicated the resident was high risk for elopement with a goal for Resident 1 to stay within the Skilled Nursing Facility (SNF) and move with purposeful behavior daily. The Care Plan indicated interventions to perform an assessment of resident risk for elopement and wandering on admission, quarterly, and as needed; attempt to have the resident verbalize their needs, frequent visual checks, and to notify the physician (MD) for any change of condition (COC). A review of Resident 1 ' s History and Physical dated 3/7/2023, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 6/12/2023, indicated the resident had severe cognitive impairment (never/rarely made decisions). The MDS further indicated Resident 1 required extensive assistance and one-person physical assistance for dressing, toilet use, and personal hygiene; and limited assistance and one-person physical assistance for bed mobility, transferring, dressing, and walking in the room and corridor. The MDS indicated Resident 1 utilized a walker. A review of a COC Note dated 6/14/2023 at 7:10 AM, indicated Certified Nursing Assistant (CNA) 2 had made initial rounds on 6/13/2023 at 10:45 PM and noticed Resident 1 was not in her room. At 11 ,PM CNA 1 noticed Resident 1 was not in her room, and informed Licensed Vocational Nurse (LVN) 2. The Note indicated LVN 2 called a code green (an activation to provide an appropriate response from staff in the event of a missing or eloping patient) for missing Resident 1. The Note indicated all the CNAs helped look for Resident 1 in the entire facility. A CNA drove around the facility within 5 miles but did not find Resident 1. The Note indicated at 11:15 PM Registered Nurse (RN) 2 arrived at the facility and did her rounds. When RN 2 noticed Resident 1 was not there, LVN 2 informed her Resident 1 was last seen at 9 PM when LVN 2 went to the resident ' s room. The Note further indicated, RN 2 called 911, reported missing Resident 1, and two police officers from the Police Department (PD) came to interview RN 2 and obtain more information regarding Resident 1. The Note indicated on 6/14/23 at 1:11 AM, MD 1 was notified that Resident 1 was missing. At 2 AM the note indicated General Acute Care Hospital (GACH) 1, GACH 2, GACH 3, GACH 4, and GACH 5 were called to inquire if Resident 1 was admitted but each GACH indicated they did not have a patient by Resident 1 ' s name. A review of a Progress Note dated 6/14/2023 at 9:45 AM, indicated Resident 1 came back to the facility at 9:15 AM, accompanied by the Director of Nursing (DON) and Infection Preventionist (IP) in stable condition. The Note indicated Resident 1 was found at her previous address around 8:20 AM. The Note indicated Resident 1 was assessed, had no complaints of pain or discomfort, and had no skin issues. The Note further indicated Resident 1 indicated she did not fall, MD 1 was made aware of the incident, and physician orders were received for a wander guard (wrist band alert system that triggers an alarm to prevent wander-prone residents from leaving unattended) and hourly monitoring of Resident 1. The Note indicated Resident 1 was educated on the importance of letting the nurses know if the resident wanted to go out on pass. A review of the distance between the facility and Resident 1 ' s previous address indicated they were both approximately 9 miles apart. A review of an Interdisciplinary Team Review (IDT - a team of professionals that plan, coordinate, and deliver personalized healthcare) Note dated 6/16/2023 at 2:46 PM, indicated Resident 1 eloped on 6/13/2023. The note indicated on 6/14/2023 at 8:15 AM the DON and IP went to Resident ' s 1 previous address on file to do a wellness check and upon arrival, Resident 1 was found sitting in her front yard; Resident 1 stated she needed to clean her front yard and that her brother brought her there. The note further indicated PD officers arrived and were able to convince Resident 1 to go back to the facility. The note indicated Resident 1 verbalized wanting to go home but due to her cognitive status, medical conditions, and because the resident lived alone, she was not safe to be discharged home. During an interview on 6/28/2023 at 10:24 AM, Resident 1 stated she left the facility about two weeks ago at around 6 PM. Resident 1 stated she got out through the front door of the facility. Resident 1 stated normally there was someone at the front, but that night when she went to the front of the facility, there was no one there and no one was watching her; so, she just walked out and left. Resident 1 stated she took the bus to her home because she did not have a car, but when she got home, she did not have the right keys so she could not get into her house. Resident 1 stated she sat on a chair on her porch the whole night. Resident 1 stated the next morning, two girls from the facility came and talked to her and brought her back to the facility. During an observation on 6/28/2023 at 12:17 PM, the facility was observed with two main doors, one by the front entrance of the facility and the other an emergency exit in front of station 2. Each door was observed with an alarm that made a loud sound when the door was opened and could only be shut off through the use of a key. During a telephone interview on 6/28/2023 at 12:57 PM, CNA 1 stated he was doing rounds at 11 PM, checked Resident 1 ' s room and saw she was not there. CNA 1 stated he asked the charge nurse who also did not know where Resident 1 was. CNA 1 stated a code green was started, 911 was called, and the staff started looking in all the rooms and bathrooms. CNA 1 stated staff went outside to check if Resident 1 was there, but she was not. CNA 1 stated a charge nurse and CNA also drove around the facility but were not able to find her. CNA 1 further indicated there was no receptionist at the front of the facility at that time because it was 11 PM. CNA 1 stated there was no alarm that night; stated that he did not think the alarm was on because many CNAs especially from the 3 PM to 11 PM shift leave the alarm off when they leave. CNA 1 further stated some CNAs leave through the front door, then the alarm goes off, then they turn off the alarm and leave, but do not turn the alarm back on. During an interview on 6/28/2023 at 2:13 PM, the Infection Preventionist (IP) stated the DON had called her early in the morning on 6/14/2023 and told her Resident 1 was missing. The IP stated they had found an address that was in the inquiry from the GACH Resident 1 came from. The IP stated she drove to Resident 1 ' s address with the DON and found Resident 1 sitting in front of the house. The IP stated Resident 1 was sitting; was awake, alert, and was able to have conversations. The IP stated Resident 1 had wet her pants, but did not realize she was wet, and stated the resident indicated her brother had picked her up at the facility. The IP further stated Resident 1 was stating her brother was coming back and just went somewhere. The IP stated out of nowhere two police officers came and were able to convince Resident 1 to come back to facility. During an interview on 6/28/2023 at 3:26 PM, Licensed Vocational Nurse (LVN) 2 stated the last time she saw Resident 1 was at 9:15 PM on 6/13/2023, when the resident was provided with dementia medication. LVN 2 stated she did not remember hearing the alarm at all that night. During an interview on 6/29/2023 at 12:28 PM, the DON stated on 6/14/2023 she and the IP drove to Resident 1 ' s address and found the resident sitting on the porch. The DON stated Resident 1 stated she had to check her mail and clean her area. The DON stated Resident 1 was in stable condition and agreed to come back to the facility. The DON further stated Resident 1 was assessed and indicated the resident did not have any injuries, was able to walk, and upon return to the facility the resident received a shower. The DON further stated Resident 1 was asked about the elopement incident and indicated her brother had picked her up. A review of the facility Policy and Procedure titled, Wandering and Elopement, dated March 2019, indicated the facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintain the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident ' s care plan will include strategies and interventions to maintain the resident ' s safety.

Apr 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Transfer (Tag F0626)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was permitted to return to the facility for one of two sampled residents (Resident 1) within the seven-day bed-hold. Resident 1 was transferred to the general acute hospital (GACH 1) on [DATE] and was ready to return to the facility the next day on [DATE] in accordance with facility's policy and procedures titled, Bed-Holds and Returns reviewed on [DATE]. The facility failed to re-admit Resident 1. This deficient practice resulted in the facility denying Resident 1 the right to return to the facility within the seven-day bed hold. Findings: A review of Resident's admission Record indicated the facility Resident 1 on [DATE] with diagnoses including dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities) and muscle weakness. A review of Resident 1's Minimum Data Set (MDS, standardized care and screening tool) dated [DATE], indicated Resident 1 was oriented to year only. Resident 1 needed one-person physical assistance with bed mobility, dressing, eating, toilet use, personal hygiene, bathing and two or more persons physical assistance with transfer. During a review of Resident 1's Physician Order dated [DATE] at 7:11 p.m., indicated to transfer Resident 1 to GACH 1 due to increased confusion and attempting to elope (when residents who are incapable of protecting themselves from harm can successfully leave the facility unsupervised and unnoticed and possibly enter harm ' s way). During a review of the Progress Notes dated [DATE] at 9:40 p.m., indicated Resident 1 left the facility by ambulance at 9:34 p.m. During an interview on [DATE] at 10:14 a.m., the social service assistant (SSA) stated the facility transferred Resident 1 to the GACH 1 on [DATE] for evaluation of aggressive behavior. The SSD stated Resident 1, is entitled to a seven-day bed hold. During an interview on [DATE] at 10:27 am., the director of nursing (DON) stated Resident 1 was transferred to the GACH 1 on [DATE]. The DON stated on [DATE] she received a call from GACH 1 that Resident 1 was ready to return to the facility. The DON stated she did not allow Resident 1 to return to the facility because she was concerned about Resident 1 ' s safety. During an interview on [DATE] at 11:08 a.m., the admission coordinator (AC) stated Resident 1 had a seven-day bed hold. The AC stated the seven-day bed hold ensures that the same bed was available for Resident 1, when he is ready to return. AC stated even if the seven-day bed hold had expired, Resident, 1 is entitled to return to the facility but may not be in the same bed he previously occupied. A review of the facility's policy and procedures titled, Bed-Holds and Returns reviewed on [DATE], indicated, the resident may return to and resume residence in the facility after hospitalization or therapeutic leave as outlined in the policy. If the resident exceeds the state ' s bed hold limit, he or she will be permitted to return to the facility to his or her previous room if available or immediately upon the first available bed of a bed in a semiprivate room provided that the resident requires the services of the facility and is eligible for skilled nursing services.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide bed hold notice upon transfer for two of two sampled residents (Resident 1 and Resident 2) in accordance with the facility's policy and procedures titled, Bed-Holds and Returns reviewed on 1/31/23, as evidenced by: 1. Resident 1 was transferred to the general acute hospital (GACH 1) on 4/21/23 and no bed hold notice was given upon transfer. 2. Resident 2 was transferred to the GACH 2 on 4/25/23 and no bed hold notice was given upon transfer. This deficient practice had the potential for residents not to know that they have the right for a seven-day bed hold. Findings: 1. A review of Resident 1's admission Record indicated the facility admitted Resident 1 indicated on 3/10/23 with diagnoses including dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities) and muscle weakness. A review of Resident 1's Minimum Data Set (MDS, standardized care and screening tool) dated 3/16/23 indicated Resident 1 was oriented to year only. Resident 1 needed one-person physical assistance with bed mobility, dressing, eating, toilet use, personal hygiene, bathing and two or more persons physical assistance with transfer. During a review of the Physician Order dated 4/21/23 at 7:11 p.m., indicated to transfer Resident 1 to GACH 1 due to increased confusion and attempting to elope (when residents who are incapable of protecting themselves from harm can successfully leave the facility unsupervised and unnoticed and possibly enter harm ' s way). During a review of the Progress Notes dated 4/21/23 at 9:40 p.m., indicated Resident 1 left the facility by ambulance at 9:34 p.m. 2. A review of the admission Record indicated the facility admitted Resident 2 on 11/19/2016 and re-admitted on [DATE] with diagnoses including muscle weakness and dysphagia (difficulty in swallowing). A review of Resident 2's MDS dated [DATE], indicated Resident 1 was disoriented to year, month, and day. Resident 2 needed one-person physical assistance with bed mobility, dressing, eating, toilet use, personal hygiene, bathing and two or more persons physical assistance with transfer. During a review of Resident 2's Physician Order dated 4/25/23 at 10:40 a.m., indicated to transfer Resident 2 to GACH 2 for swallowing evaluation. During a review of Resident 2's Progress Notes dated 4/25/23 at 11 a.m., indicated Resident 2 was transferred to GACH 2. During an interview on 4/28/23 at 11:08 a.m., the admission coordinator (AC) stated she was unable to find documentation that the bed hold notices were given when Resident 1 was transferred to GACH 1 on 4/21/23 and when Resident 2 was transferred to GACH 2 on 4/25/23. The AC stated the bed hold notice will let the residents know that there is a bed available for them when they return to the facility. During an interview on 4/28/23 at 11:25 a.m., the director of nursing (DON) confirmed that the bed hold notices were not given to Resident 1 when transferred to GACH 1 and to Resident 2 when transferred to GACH 2. A review of the facility's policy and procedures titled, Bed-Holds and Returns reviewed on 1/31/23, indicated, prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy.

Apr 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 3 (CNA 3) did not eat in a resident's room and wear a face mask on (A type of Personal Protective Equipment [PPE] protective clothing, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) to help prevent the spread of infections during the Coronavirus (COVID-19 - an illness caused by a virus that can spread from person to person) crisis. This deficient practice had the potential to result in the spread of infections that could lead to serious harm and/or death to all residents and staff. Findings: During a concurrent observation and interview on 4/24/2023 at 12:50 PM, CNA 3 was observed eating food in resident room A. CNA 3 was without a face mask and was standing over residents while the residents ate lunch. CNA 3 stated he was eating chocolate candy because he was hungry and had removed his face mask to quickly eat the chocolate candy. CNA 3 stated he was required to wear a face mask on while in the facility. CNA 3 stated he was not supposed to eat in residents' rooms. CNA 3 stated he failed to follow facility's policy and procedures for infection control and that he could potentially spread infection to all residents and staff. During an interview on 4/24/2023 at 2:06 PM, Infection Control Preventionist (ICP) stated all facility staff are required to wear face mask while in the facility except for in the designated area. The ICP stated staff, can only eat and drink in the designated break areas and that residents ' rooms are not designated break area for staff. The ICP stated CNA 3 should not be eating in resident rooms with his surgical mask off. The ICP stated CNA 3 failed to follow policies and procedures on infection control and PPE policy by eating in a resident's room without a facemask. The ICP stated, the potential outcome is the spread of infection and COVID-19 to all residents and staff. During an interview on 4/25/2023 at 1:29 PM, Administrator (Admin) stated all facility staff are required to wear face mask and other PPE while in the facility except for in the designated area. He stated staff can only eat and drink in the designated break areas. He stated staff should not be eating in resident rooms. He stated CNA 3 failed to follow infection control and PPE policy and procedure by eating without a facemask in resident room and the potential outcome is the spread of infection and COVID-19 to all residents and staff. A review of the facility ' s policy and procedures titled, Break Periods, reviewed 4/2023, indicated, breaks must be taken in the cafeteria, employee dining room, employee lounge, or in similarly designated non-work areas. No food or beverage is permitted in work area. A review of the facility ' s, COVID-19 Facilities Guidance, revised 4/24/2023, indicated, the purpose of this guidance is to adhere to the revised regulatory requirements and to keep staff safe by delivering safe practices to prevent the spread of COVID-19. All facility staff, vendors and visitors will adhere to the protocols and guidance as follows: masking is required of all staff.

Apr 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed report the allegation of abuse to the state survey agency (SSA) within 2 hours for one of three sampled residents (Resident 1). Resident 1 alleged on 4/17/23, the licensed vocational nurse (LVN 1), grabbed her hands and as a result, Resident 1 stated she developed bruises on the left and right hands. This deficient practice resulted in delay of the investigation of the allegation of abuse and failed to protect Resident 1 from further emotional and psychosocial distress. Findings: During a review of Resident 1's admission Record indicated Resident 1 was admitted on [DATE] with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and major depression. A review of Resident 1's Minimum Data Set (MDS, standardized care and screening tool) dated 3/24/23 indicated Resident 1 was oriented to year, month, and day. Resident 1 needed supervision (oversight, encouraging or cuing) with bed mobility, transfer, eating, toilet use and limited assistance (resident highly involved with activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance) with dressing, personal hygiene, and bathing. A review of Resident 1's Nursing Progress Notes dated 4/18/23 at 3:53 a.m., indicated Resident 1, came out of her room, and wanted to see the old bottle of the Latanoprost eyedrops (medication for glaucoma [a group of eye diseases that can cause vision loss and blindness by damaging the nerve in the back of the eyes]. The Notes indicated Licensed Vocational Nurse 1 (LVN 1) showed Resident 1 the bottle of the Latanoprost, and Resident 1 stated she would keep the bottle in her room. LVN 1 informed Resident 1 that she cannot keep the bottle in her room. The Notes indicated Resident 1 held on to the medication bottle tightly with her hands and refused to return the bottle. Resident 1 started yelling, grabbed, and pulled on LVN 1 ' s jacket and clothes. Resident 1 finally opened her hand and released the bottle of eyedrops. Resident 1 was assisted back to her room and into her bed. A review of Resident 1's Change in Condition Evaluation dated 4/18/23 at 11:53 a.m., indicated Resident 1 had senile purpura (bruises due to fragile skin) on the back of the right and left hand. The primary physician was notified and gave order to monitor the site for 72 hours. During an observation and a concurrent interview on 4/19/23 at 11:11 a.m., Resident 1 was observed with bruises on the back of the left and right hands. Resident 1 (through a translator) stated on 4/17/23, at about 9 p.m., LVN 1 instilled eyedrops in her eyes and her eyes became irritated. Resident 1 stated she wanted to see the eyedrop bottle, keep it and discard the bottle. Resident 1 stated LVN 1 grabbed her hands to get the bottle and as a result bruises developed in her hands. Resident 1 stated LVN 1 .was a mean nurse, and no one hurt me like that before. Resident 1 further stated she was scared of LVN 1. During an interview on 4/19/23 at 12:33 p.m., Certified Nurse Assistant 1 (CNA 1) stated Resident 1 told him about the abuse allegation on 4/18/23 that LVN 1 grabbed her hands and caused the bruises. CNA 1 stated on 4/18/23, he informed LVN 2 and LVN 3 about Resident 1's abuse allegation. During an interview on 4/19/23 at 1:55 p.m., the director of nursing (DON) stated no one reported Resident 1's allegation of abuse. DON stated everyone is a mandated reporter. DON stated we must know so the facility can properly investigate what happened. DON further stated any allegation should be reported to the administrator or to the DON. During an interview on 4/19/23 at 2:06 p.m., the administrator (ADM) stated no one reported any allegation of abuse involving Resident 1. ADM stated if he had known, he would report within two hours of knowing the allegation to the SSA and provide a five-day report. During a telephone interview on 4/19/23 at 4:15 p.m., LVN 1 stated on 4/17/23 at about 11 p.m., Resident 1 asked to see the bottle of the eyedrop and wanted to keep it. LVN 1 stated she gave the bottle to Resident 1 and Resident 1 wanted to keep the bottle. LVN 1 stated she asked for the bottle back but Resident 1 refused. Resident 1 became angry, agitated, and started pulling on LVN 1's jacket and clothes. LVN 1 stated she did not grab Resident 1's hands. During a telephone interview on 4/19/23 at 4:31 p.m., CNA 2 stated Resident 1 tried to keep the empty bottle of the eyedrops and started pulling on LVN 1 ' s jacket and clothes. CNA 2 stated LVN 1 placed her hand on Resident 1's hands and asked Resident 1 to please let go. CNA 2 stated LVN 1 did not forcefully held Resident 1 ' s hands. During a telephone interview on 4/20/23 at 12:04 p.m., LVN 2 stated no one reported Resident 1 ' s allegation to him. During a telephone interview on 4/20/23 at 3:38 p.m., LVN 3 stated no one reported Resident 1 ' s allegation of abuse. During a review of the facility's policy and procedures titled Abuse Investigation and Reporting, reviewed on 1/31/23, indicated all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. The same policy indicated an alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two hours if the alleged violation involves abuse or has resulted in serious bodily injury or b. 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury.

Mar 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to protect the residents ' right to be free from verbal abuse by Director of Social Services for two of two sampled residents (Resident 1 and Resident 2).Director of Social Services verbally abused Resident 1 and Resident 2 on two separate occasions. This deficient practice has caused Residents 1 and 2 psychological effects and the feeling of fear. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including osteomyelitis (a bone infection) , high blood pressure and chronic kidney disease (disease in which the kidney is unable to filter properly). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care-screening tool) dated 12/30/2022, indicated the resident ' s cognition was intact. The MDS also indicated Resident 1 required extensive assistance with one-person physical assist with activities of daily living (bed mobility, transfer, toileting, and personal hygiene). A review of Resident 1's Change in Condition (COC) form dated 2/20/2023, timed at 4:38 PM, indicated Resident 1 was at risk for fear, emotional distress and negative psychosocial impact related to conflict with staff member. A review of the Physician's Order dated 2/20/2023, indicted Resident 1 may have a psychology consult and to monitor resident for any signs and symptoms of emotional distress and psychological negative impact every shift. A review of Resident 1's progress note dated 2/20/2023, timed at 5:11 PM indicated the resident met with facility administrator and expressed concern regarding a conversation he had with the Social Services Director. It also indicated the resident stated the SSD made an inappropriate comment regarding his wound healing status and discharge planning. It indicated Resident 1 would be placed on monitoring for emotional distress, negative psychosocial impact and fear for 72 hours. A review of Resident 1's risk for psychosocial impact care plan initiated 2/20/2023, after the alleged abuse indicated that the resident was at risk for negative psychological impact, emotional distress and fear due conflict with staff member. The care plan interventions included to maintain a calming environment, offer to talk with resident and psychiatric consult and evaluation. A review of the Psychotherapy Consultation, dated 2/21/2023, indicated that Resident 1 was upset by the comments made to him by the social services designee and was unable to sleep that night. During an interview on 2/28/2023 at 11:14 AM, Resident 1's Family Member (FM) 1 stated, Resident 1 told him it was not the right the way he was being spoken to by the Social Services Director (SSD). FM 1 also stated that Resident 1 told him that Resident 1 and Resident 2 were basically being told by SSD that there were other patients waiting and apparently those other patient s were paying customers. It was inferred that you guys have Medi-Cal, so you guys are not paying. During an interview on 3/1/2023 at 2:24 PM, Resident 1 stated on 2/17/2023, Social Services Director (SSD) told him to that she needed him gone and out of the facility because she needed his bed. Resident 1 further stated that she said this three times. Resident 1 stated that this made him scared because he felt that the facility was going to throw him out before he was healed. Resident 1 further stated I didn ' t sleep; it really got to me. A review of Resident 2's admission record indicated the facility admitted the resident on 7/6/2022, with diagnoses including surgical amputation, muscle weakness and neuralgia. A review of Resident 2 ' s MDS, dated [DATE], indicated the resident ' s cognition was intact and required extensive assistance with one-person physical assist with bed mobility, transferring, transferring, eating, dressing, toileting and personal hygiene. A review of Resident 2's progress note dated 2/20/2023 indicated the resident met with facility administrator, and expressed concern regarding a conversation he had with SSD. It also indicated Resident 2 stated SSD made an inappropriate comment regarding his legal status and he expressed an emotional disturbance regarding the conversation. A review of Resident 2's risk for psychosocial impact care plan initiated 2/20/2023, after the alleged abuse indicated that the resident was at risk for negative psychological impact, emotional distress and fear due conflict with staff member. The care plan interventions included to maintain a calming environment, offer to talk with resident and psychiatric consult and evaluation. A review of Resident 2's Physician's Order, dated 2/20/2023 indicated to monitor resident for signs and symptoms of emotional distress and psychological negative impact every shift and to notify the physician for any significant changes. A review of the facility's Notice to Employee as to Change in Relationship, form, dated 2/20/2023 indicated the SSD ' s employment was discontinued on 2/20/2023. A review of Resident 2's Psychotherapy Consultation, dated 2/21/2023 indicated Resident 2 expressed concern regarding a conversation he had with the SSD and the resident was upset. It also indicated psychological interventions used with the resident included active and reflective listening and cognitive strategies designed to assist him in better tolerating and managing his feelings. It also indicated the resident demonstrated modest improvement in his response to care at the facility particularly an improvement in his agitation but he continued to exhibit anxiety. A review of Licensed Vocational Nurse (LVN) 1's written statement, dated 2/20/2023, indicated in January 2023 an interdisciplinary team (IDT, - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) meeting was conducted with Resident 2 and those present were LVN 1, Social Services Director, Admissions Concierge (AC) and Receptionist (RCP). It further indicated Resident 2 expressed his disagreement as well as his desire to leave as soon as he received a new prosthetic leg. The SSD responded with a sentiment to the effect of ' you have nowhere to go because of your no paper status ' which was translated to the resident. A review of the Admissions Concierge (AC) written statement, dated 2/20/2023, indicated she was asked to translate for SSD while speaking to Resident 2 regarding his behavior towards staff. It also indicated the resident expressed that he wanted to leave as he received his prosthetic leg and the SSD asked her to translate to Resident 2 that because of his non-immigrant status, we will not be able to discharge him asap. During an interview on 3/1/2023 at 2:29 PM, Resident 1 (Resident 2's current roommate) stated that a month prior to his incident with the SSD, he witnessed the SSD with two interpreters direct the translator to tell Resident 2 he had no rights here because he had no papers. During an interview on 3/1/2023 at 2:32 PM, Resident 2 stated while conversing with the SSD in his room with other facility staff translating for the SSD, the SSD told Resident 2, he needed to behave because he had nowhere to go, he had no papers to live here in this country. Resident 2 stated this made him feel uncomfortable and he replied, Just because I don ' t have papers doesn ' t mean I don ' t have rights. Resident 2 further stated that the SSD needed to behave because Resident 2 didn ' t have papers (immigration status documents). During an interview with on 3/2/2023 at 2:57 PM, the Director of Staff Development (DSD) stated that in the past she received complaints about the SSD ' s approach, which was not always welcoming and could be aggressive. During an interview on 3/2/2023 at 3:30 PM, the AC stated sometime in January 2023, she was asked to translate for the SSD with Resident 2. The AC stated during the conversation the SSD wanted translated to the resident that because of his immigration status the facility could not discharge him right away. During a phone interview on 3/9/2023 at 8:20 AM, the Receptionist (RCP) stated that in January 2023 she was asked to translate for the SSD inside Resident 2 ' s room. During the conversation after Resident 2 stated he wanted to leave the facility as soon as possible, the SSD stated that because of Resident 2 ' s no-paper status he could not leave right away. The RCP stated that she did not know what SSD meant by no paper status and stated that whenever SSD speaks to people, she sounds aggressive. During an interview on 3/22/2023 at 10:42 AM, Administrator (ADM) stated that Resident 1 and Resident 2 reported the incidents with the SSD on Monday 2/20/2023, and he then reported the incident to Public Health. The ADM further stated that he terminated SSD because she did not fit the culture of my building. A review of the facility policy and procedure titled, Resident Rights, indicated facility employees will treat all residents with kindness, respect and dignity. A review of the facility's policy and procedure titled, Abuse Prevention Program, revised 12/2016, indicated the residents have the right to be free from abuse and neglect, including verbal abuse. The policy indicated the administration would protect the residents from abuse by anyone including other residents or any other individual.

Feb 2023 2 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review, the facility failed to maintain and document a monthly tracking surveillance logs to help identify patterns, rates, and possible outbreaks in the facility. This deficient practice had the potential to result in the transmission of disease and infection. Findings: On 2/3/2023 at 11 a.m., during an interview and concurrent record review with the Infection Preventionist Nurse (IPN), she stated there were no monthly tracking logs maintained by the facility to track signs and symptoms of possible infections to help identify possible outbreaks. The IPN stated there was only one symptom reported in the facility last week on Tuesday and Wednesday. The symptom was body ache. The IPN provided an infection control surveillance log that included residents on antibiotics. The log failed to include past or present signs and symptoms of infection that did not result in an order with antibiotic. During a consequent interview with the IPN, on 2/3/2023 at 11:20 a.m., the IPN stated she monitors for an outbreak by: 1. Monitor signs and symptoms on daily basis and not on a log. 2. Reviews a dashboard for alert for residents with symptoms. The IPN verified she was not able to identify an outbreak with her current system. According to the Centers of Disease Control and Prevention (CDC) recommendations, dated 6/19/17, long term care (LTC) facilities should track infections. Tracking infections help eliminate infections, many of which were preventable, improve care, and decrease costs. When facilities track infections, they can identify problems and track progress toward stopping infections. https://www.cdc.gov/nhsn/ltc/index.html A review of the facility policy and procedure titled, Surveillance for Infections, revised 9/2017, indicated the Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and preventive interventions to identify outbreaks.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview, and record review, the facility failed to provide written education in Spanish, regarding the benefits and risks of immunization and administration for the influenza (Flu-a contagious respiratory illness), pneumonia (PNA-an infection of the lungs), and COVID-19 (a highly contagious respiratory disease) vaccinations (medication to prevent a particular disease) to the monolingual Spanish speaking residents. This deficient practice had the potential to deprive the residents and their representatives of the right to make an informed decision regarding vaccinations. Findings: A review of the available vaccine information statements provided to residents and their representative's regarding influenza, pneumococcal conjugate vaccine, and COVID-19 vaccine, was provided in English only. No written information regarding any vaccines were found in Spanish or any other language. During an interview on 2/3/2023, at 12:40 p.m. the Infection Preventionist Nurse (IPN) stated written information regarding vaccinations was provided in English. The IPN further stated the facility did not have any written material in Spanish. The IPN verified the facility population was composed of both English and Spanish speaking residents. A review of the facility's policy dated 2/16/2022, titled Coronavirus Disease (COVID-19) - Vaccination of Residents, indicated information was provided to the resident in a format and language that was understood by the resident or representative.

Oct 2021 10 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide an environment free of accident hazards and supervision for one of two sampled residents, (Resident 3), who was a high fall risk and had history of falls with fracture (broken bones). On 10/16/2021, at 9 AM, the Certified Nursing Assistant 1 (CNA 1) assisted the resident to the activity room, where Resident 3 remained alone, unsupervised. As a result, at 9:20 AM, Resident 1 was found in the activity room, lying on her left side near her wheelchair, and complained of moderate pain to the left hip and left thigh. On 10/17/2021, Resident 3 was diagnosed with a left hip fracture requiring transfer to General Acute Care Hospital (GACH) on 10/18/2021. Findings: A review of the admission Record indicated Resident 3, a [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses including history of falling, wedge compression fracture T9-T10 vertebra (a fracture in the front part of the thoracic, pelvis vertebra), wedge compression fracture of lumbar vertebra (a fracture in the front part of the lumbar vertebra), osteoporosis (bones become weak and brittle). A review of Resident 3's Fall Risk assessment dated [DATE], indicated Resident 3 had a balance problem while standing, walking, and required the use of assistive devices. The fall risk assessment indicated Resident 3 was a high risk for falls. A review of Resident 3's care plan dated 6/23/2021, indicated Resident 3 was at risk of self-care deficit due to inability to participate in any independent activity of daily living related to impaired cognition, impaired physical mobility, impaired balance, limited mobility, and limited range of motion. The care plan indicated Resident 3 required extensive assistance with most of her activities of daily living. A review of Resident 3's care plan for history of falls, poor balance and decrease in functional status developed 6/23/2021, included the interventions to assist with all transfers or ambulation, call light within reach and answered promptly, encourage the resident to use it for assistance as needed. The care plan intervention indicated Resident 3 needed prompt response to all request for assistance and encourage the resident to call for assistance before attempting to transfer or ambulate if able. According to a review of Resident 3's care plan for osteopenia (bone loss), osteoporosis (weak and brittle bones), and osteoarthritis (degenerative joint disease) developed 6/23/2021, Resident 3 was at risk for pathological fracture (a break in a bone caused by underlying disease). The care plan interventions included to assist the resident during transfer safely, maintain safe and hazard free environment, handle gentle when positioning, and place call light within reach. A review of the Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 6/30/2021, indicated Resident 3 required extensive assistance (staff provide weight-bearing support) with one person assist for bed mobility, dressing, eating, toilet use and personal hygiene. The MDS indicated Resident 3 was not steady for surface-to-surface transfer, between bed and chair, wheelchair, and standing position. A review of Resident 3's Medication Administration Record dated 8/1 - 8/31/2021 and 9/1 - 9/30/2021, indicated Resident 3 was being monitored for muscle weakness, tender and sore muscles. A review of Resident 3's Change of Condition (COC) notes dated 10/16/2021, indicated at 9:20 AM, the Activities Assistant reported to the Registered Nurse (RN 1) that Resident 3 was found in the activity room, lying on her left side near her wheelchair, and complained of moderate pain to the left hip and left thigh. The charge nurse medicated Resident 3 for pain, with frequent visual checks done by staff for safety. The COC indicated when the physician was notified, he ordered for X-ray (a photographic or digital image of the internal composition of a part of the body) of bilateral hips, pelvis, and left thigh. According to a review of the Radiology Report, dated 10/17/2021, Resident 3 suffered a comminuted left intertrochanteric fracture (a break with multiple pieces and fracture lines in the hip) and superolateral displacement of the distal fragment (bone breaks into two or more pieces and moves out of alignment). During an observation and interview with Resident 3 on 10/18/2021 at 9:20 AM, Resident 3 was awake, alert, Spanish speaking and stated no one paid any attention her. Resident 3 stated sometimes the staff yell at her. Resident 3 grabbed her left leg and stated she fell in the activities room on 10/16/2021 in the morning, and she was having pain. A review of Residents 3's Progress Notes dated 10/18/2021, indicated the Medical Doctor was notified of Resident 3's x-ray results and gave new orders to transfer Resident 3 to the General Acute Care Hospital for evaluation (two days after the fall). A review of the GACH History and Physical (H&P) dated 10/19/2021, indicated Resident 3 was admitted to the GACH on 10/18/2021 from a nursing home where she fell, developed left sided pain and was brought to the hospital due to a left hip fracture, awaiting orthopedic consult. During an interview with Registered Nurse (RN 1) on 10/19/2021 at 10 AM, Registered Nurse 1 (RN 1) stated she was working day shift on 10/16/2021 and around 9:20 AM she was paged to go to the activities room because a resident fell on the floor. The receptionist went on his break and the activities assistant went to cover the receptionist break. RN 1 stated, At the time no one was inside the activities room supervising the resident (Resident 3). RN 1 stated she went to assess Resident 3 and assisted the resident back to the wheelchair and back to bed. Resident 3 was complaining of a pain rated at level of 6 out of 10 pain (moderate pain). RN 1 stated the charge nurse gave Resident 3 Tylenol (pain medication) and notified the Medical Doctor of the fall. The Medical Doctor ordered for Resident 3 to receive x-rays. During an interview with Director of Nurses (DON) on 10/19/2021 at 11 AM., she stated she did not know why Resident 3 was left alone in the activities room. During an interview with Activities Director (AD) on 10/20/2021 at 1 PM, he stated he did not work on the weekends, but if there were residents in the activities room, then a staff member should always be inside the activities room. On 10/20/2021 at 1:15 PM, during a telephone interview with the Activities Assistant (AA), he stated the morning of the fall on 10/16/2021 was a busy day, and he was asked to cover the receptionist that went on break. The Activities Assistant stated at the time, he was checking people in to the facility, answering the phones, and he saw Resident 3 in the activities room by herself. The AA stated he was unsure why the CNA left Resident 3 inside the activities room, but she was not supposed to leave her in the activities by herself. The AA stated, he could see Resident 3 in the activities room attempting to get up, so he went to get the RN 1 and when they went into the activities room, Resident 3 was already on the floor. During a telephone interview with Certified Nurse Assistant (CNA 1) on 10/21/2021 at 11:20 AM, CNA 1 stated she assisted Resident 3 out bed into the wheelchair as requested by the resident. Resident 3 told her she wanted to go inside the activities room and to sit her by a table. CNA1 stated the activities door was open, and she could see there was someone outside the activity room, at the reception desk but failed to notify anyone that she was leaving the resident inside the activities room. A review of the GACH Orthopedic Surgery Consultation Note dated 10/21/2021, indicated Resident 3 benefitted from surgical fixation of the left hip fracture but she had a change in condition. Resident 3 had significantly worsening difficulty breathing and required continuous face mask with high flow oxygen. During an interview with the Administrator (ADM) on 10/22/2021 at 11 AM, the ADM stated someone should have been inside the activities room with Resident 3 because it was good practice. The ADM stated the CNA left Resident 3 in the activity room and the fall was not reported. A review of the GACH Neurology Consult dated 10/25/2021, indicated Resident 3 was transferred to the Intensive Care Unit due to cardiac arrest (unexpected loss of heart function). Resident 3 was intubated (a flexible plastic tube into the windpipe to maintain an open airway) and sedated. Neurology was consulted for seizure like activity with irregular movement of upper body, lasting a couple of seconds. No history of seizures. During a telephone interview on 11/1/2021 at 9:30 AM, the DON stated Resident 3's care plans did not address that the resident needed to be supervised to prevent falls. A review of the facility's policy and procedure titled, Falls and Fall Risk Managing, revised March 2018, indicated the staff will identify interventions related to the resident's specific risks and try to prevent the resident from falling and try to minimize complications from falling. The staff with the input of attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. A facility policy was requested regarding supervision in the activity room, it was n

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accommodate the needs of one of 35 sampled residents (Resident 45) when Resident 45's call light (device used to call for assistance from the facility staff) was observed hanging off the resident's bed. This deficient practice had the potential for Resident 45 to have the inability to call the facility staff for help when needed. Findings: A review of Resident 45's Facesheet indicated, Resident 45 was admitted to the facility on [DATE], with diagnoses including osteoarthritis (a disease caused by aging joints which results in pain, swelling, and reduced motion in the joints), contractures (a condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) in both the left and right knee. A review of Resident 45's Care Plan, dated 7/8/2021, indicated Resident 45 was at risk for spontaneous fracture due to Vitamin D (a vitamin that is essential for absorption of calcium in the body, deficiency). The interventions included to have the call light within reach and to answer promptly. A review of Resident 45's Minimum Data Set (MDS - a comprehensive standardized assessment and care screening tool), dated 8/19/2021, indicated Resident 45 had severe cognitive impairment and was totally dependent or required extensive assistance from staff for activities of daily living (ADL). During an observation and concurrent interview, on 10/19/2021, Resident 45 was observed lying in bed with the call light hanging off the head of her bed. Resident 45 stated she was unable to reach for the call light and call for help if she needed to. A review of the facility's policy and procedure (P&P) titled, Answering the Call Light, dated 10/2010, indicated when the resident was in bed or confined to a chair, be sure the call light was within easy reach of the resident.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a homelike environment for two of 35 sampled residents (Resident 45, Resident 24) when Resident 45 stated the noise levels in the facility bothered her and Resident 24 could hear staff clock out. This deficient practice caused an increase risk to disturb the sleep schedule of the residents and not allow them to receive enough rest. Findings: A review of Resident 45's Facesheet indicated, Resident 45 was admitted to the facility on [DATE], with diagnoses including osteoarthritis (a disease caused by aging joints which results in pain, swelling, and reduced motion in the joints), contractures (a condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) in both the left and right knee. A review of Resident 45's Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool), dated 8/19/2021, indicated Resident 45 had severe cognitive impairment and was totally dependent or required extensive assistance from staff for activities of daily living (ADL). During an interview with Resident 45, on 10/19/2021, at 2:52 PM, Resident 45 stated that it was sometimes noisy outside her room and it bothered her. Resident 45 further stated she had a hard time sleeping at night when it was noisy. A review of Resident 24's Facesheet indicated, Resident 24 was admitted to the facility on [DATE] with diagnoses including diabetes (a disease that affects the way the body processes blood sugar), and hypertension (high blood pressure). A review of Resident 24's Minimum Data Sheet (MDS), dated [DATE], indicated Resident 24 was cognitively intact. During an interview with Resident 24, on 10/20/2021, at 12:01 PM, Resident 24 stated the room gets loud when staff clock out for their breaks. Resident 24 further stated she can sometimes hear noise coming from the neighboring rooms and it gets loud. During an observation on 10/20/2021, at 12:05 PM, outside Resident 45 and Resident 24's room, the sound of other residents, facility staff, and resident's television can be heard. During an observation on 10/20/2021, at 12:06 PM, in the hallway in front of Resident 45 and Resident 24's room, a timekeeping station was observed. During an interview with Certified Nursing Assistant (CNA) 5, on 10/20/2021, at 12:13 PM, CNA 5 stated Resident 45 complained to her that she can hear another resident making too much noise and it bothered her and made her angry. CNA 5 further stated she closed the door to Resident 45's room to keep the noise out. A review of the facility's policy and procedure (P&P) titled, Quality of Life - Homelike Environment, dated 5/2017, indicated residents were provided with safe, clean, comfortable, and homelike environment. The P&P further indicated the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting, including comfortable noise levels.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility failed to ensure an accurate assessment was conducted for one of three sampled residents (Resident 3). Resident 3 did not have an accurate assessment for cognitive skills for daily decision making. This deficient practice had the potential to result in Resident 3's delay in necessary care and treatment. Findings: A review of the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including history of falling, wedge compression fracture T9-T10 Vertebra (a fracture in the front part of the thoracic vertebra), wedge compression fracture of lumbar vertebra (a fracture in the front part of the lumbar vertebra), hypertension (high blood pressure), and osteoporosis (when bones become weak and brittle). A review of the Resident 3's History and Physical dated 6/24/2021, indicated Resident 3 had the capacity to understand and make decisions. Resident 3 was alert oriented to person, place, and time. A review of Resident 3's Nursing Progress Notes dated 8/8/2021, indicated Resident 3 resting comfortably in bed, alert and oriented to person, place, and time and was able to verbalize needs and concerns. A review of Resident 3's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 9/29/2021, indicated Resident 3 was severely cognitively impaired for daily decision making. During an observation and interview, on 10/18/2021 at 9:20 AM, Resident 3 was noted awake, alert, Spanish speaking and stated she was having trouble hearing, but no one paid any attention. Resident 3 grabbed her left leg and stated she fell in the activities room over the weekend, and she was having pain. During an interview with Director of Nurses (DON) on 10/20/2021 at 1 PM, the DON stated, the Social Worker was in charge of Resident 3's assessment for cognition and she would in service the Social Worker because the assessment was not accurate. During an interview with Certified Nurse Assistant (CNA 1) on 10/21/2021 at 1:30 PM. CNA 1 stated, Resident 3 was able to verbalize needs in Spanish. Resident 3 reported to her that she was having trouble hearing from both ears and this was reported to her charge nurse. A review of the facility's Policy and Procedure titled, Comprehensive Assessments and the Care Delivery Process, revised December 2016, indicated comprehensive assessments will be conducted to assist in developing person-centered care plans. Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and monitoring results and adjusting interventions. Assessment and information collection includes what, where, and when. The objective of the information collection phase was to obtain, organize, and subsequently analyze information about a patient.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow professional standards of practice and implement a physician's written order for a pain management consult for one of three sampled residents (Resident 17). This deficient practice had the potential to place Resident 17 at risk for increased levels of pain and a decrease in daily function. Findings: A review of the admission Record indicated Resident 17 was admitted to the facility on [DATE] with diagnoses including polyarthritis (joint pain that affects five or more joints), chronic pain, muscle weakness, rheumatoid arthritis (an inflammatory disorder affecting many joints), spinal stenosis (narrowing of the spaces in the spine causing pressure on the nerves), and cardiomegaly (an enlarged heart). A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated 7/8/2021, indicated Resident 17 had intact cognitive skills for daily decision making. Resident 17 required extensive one person physical assistance with bed mobility and two person assistance with transfers. A review of Resident 17's Physician's Order dated 7/15/2021, indicated an active order for pain management consult. During an interview with Resident 17 on 10/18/2021 at 9:45 AM, Resident 17 stated she had not been seen by a pain management doctor since she was admitted to the facility. During an interview with Social Worker (SW) on 10/28/2021 at 9:50 AM, the SW stated Resident 17 had an active order pain management consult, but could not see from the records that Resident 17 had been seen and the nurses were responsible to make the appointments. During an interview with Licensed Vocational Nurse (LVN 1) on 10/21/2021 at 11 AM, LVN 1 stated she can not find any records indicating Resident 17 had been seen by the pain management doctor. During an interview with Director of Nurses (DON) on 10/21/2021 at 1 PM, the DON stated Resident 17 was seen by a Rheumatologist, but can not find any notes when the pain management doctor came to the facility. The DON stated moving forward she will make sure to follow up with resident consultation appointments. A review of the facility's policy and procedure titled, Social Services Referrals, undated, indicated Social services personnel shall coordinate most resident referrals with outside agencies. Social Services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been or ordered by the physician.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident received proper assistive devices to maintain hearing abilities by not assisting in the arranging for an audiologist referral consult for one of three sampled residents (Resident 3). This deficient practice resulted in a delay of services and Resident 3 not being able to hear adequately. Findings: A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including history of falling, wedge compression fracture T9-T10 Vertebra (a fracture in the front part of the thoracic vertebra), wedge compression fracture of lumbar vertebra (a fracture in the front part of the lumbar vertebra), and hypertension (high blood pressure), A review of Resident 3's Order Summary Report, dated 6/22/2021, indicated an order for Ear Nose Throat (ENT) evaluation and treatment. A review of the Resident 3's History and Physical dated 6/24/2021, indicated Resident 3 had the capacity to understand and make decisions. Resident 3 was alert oriented to person, place, and time. A review of Resident 3's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 9/29/2021, indicated Resident 3's cognitive level was severely impaired and had adequate hearing. During an observation and interview, on 10/18/2021 at 9:20 AM, Resident 3 was awake, alert, Spanish speaking and stated she was having trouble hearing, but no one paid any attention and sometimes the staff yell at her. During an interview on 10/21//2021 at 1 PM, Resident 3's roommate stated, she over heard Resident 3 reporting to different staff that she was having a hard time hearing. During an interview with Certified Nurse Assistant 1 (CNA 1) on 10/21/2021 at 1:30 PM. CNA 1 stated, Resident 3 reported to her that she was having trouble hearing from both ears and this was reported to her charge nurse. During an interview on 10/21/2021 at 2 PM with Director of nurses (DON) the DON stated, the Certified Nurse Assistant knows to report to the charge nurse and then the charge nurse goes to the resident to validate the findings. The nurses are supposed to use a form called the Stop and watch form for communication. The DON stated she was not sure why the charge nurse was unaware but she will make sure to in service the staff about communicating change of condition and setting up medical appointments for the residents.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0836 (Tag F0836)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review, the facility failed to meet State licensure requirements for Physical Therapy and Occupational Therapy to have a hands-free sink in the rehabilitation room as outlined in the California Code of Regulations, Title 22. This deficient practice had the potential to prevent a sanitary environment in the rehabilitation area. Findings: During an interview, on 10/19/2021, at 11 AM, in the rehabilitation gym, the Physical Therapist stated they do not have a hands-free sink inside the rehabilitation room and they have to go outside to the nurses station to wash their hands. During an interview with the Administrator (ADM) on 10/19/2021 at 11:20 AM, the ADM stated there was no hands-free sink inside the rehabilitation room. A review of California Code of Regulations, Title 22, Division 5, Chapter 3, Section 72411 and Section 72421 indicated the Physical Therapy and Occupational Therapy space requirement indicated a sink shall be provided in the treatment area and shall have controls other than hand controls.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices for three of 36 sampled residents (Resident 45, Resident 62 and Resident 85) by failing to accurately document Restorative Nursing Assistant (RNA) interventions performed on Resident 45 and Resident 62. The facility failed to document records accurately and completely when administering a narcotic medication to Resident 85. These failures had the potential to result in the lack of or delay of care services to the residents as well as the potential to result in confusion and incomplete assessment of the resident's needs. Findings: a. A review of Resident 45's Face sheet indicated, Resident 45 was admitted to the facility on [DATE], with diagnoses including osteoarthritis, (a disease caused by aging joints which results in pain, swelling, and reduced motion in the joints), contractures, (a condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints), in both the left and right knee. A review of the Minimum Data Set (MDS - a comprehensive standardized assessment and care screening tool), dated 8/19/2021, indicated Resident 45 had severe cognitive impairment. The MDS indicated Resident 45 was totally dependent or required extensive assistance from staff for activities of daily living (ADL). A review of Resident 45's Order Summary Report, dated 8/18/2021, indicated Resident 45 had an order for splinting on the hip and knee using an extensor/abductor pillow (a device used to stretch and extend the leg, five days a week for five hours). The order summary report indicated an additional order for passive range of motion (PROM) to bilateral, both, upper extremities and bilateral lower extremities five times a week. A review of Resident 45's Care Plan, dated 8/24/2021, indicated Resident 45 was at risk for decline in range of motion (ROM) and/or contracture. The care plan interventions included RNA for ROM exercises as ordered and splint application by RNA as ordered. A review of Resident 45's Documentation Survey Report, dated 9/7/2021, with RNA 3, indicated blank spaces under splint application and PROM. During an interview and record review on 10/20/2021, at 2:25 PM, RNA 3 stated the blank spaces indicated there was no documentation performed and documentation of refusal or performance of activity should be documented. b. A review of Resident 62's Facesheet indicated Resident 62 was admitted to the facility on [DATE], with diagnoses including contracture of muscle on both the right and left arm, functional quadriplegia, and paralysis of all four limbs. A review of Resident 62's Order Summary Report, dated 6/11/2020, indicated Resident 62 had an order for the RNA to perform active assistive range of motion (AAROM) to bilateral lower extremities five times a week. A review of Resident 62's Order Summary Report, dated 11/12/2020, indicated Resident 62 had an order for the RNA to perform AAROM to bilateral upper extremities five times a week. A review of Resident 62's MDS, dated [DATE], indicated Resident 62 was cognitively intact and was totally dependent on staff for ADLs. A review of Resident 62's Care Plan, dated 9/15/2021, indicated Resident 62 was at risk for decline in ROM and/or functional mobility. The care plan interventions included RNA performs AAROM on bilateral upper and lower extremities five times a week as tolerated. A review of Resident 62's Documentation Survey Report, dated 9/3/2021, indicated blank spaces under ADL - walk in the room. A review of the Documentation Survey Report dated 9/24/2021 indicated blank spaces under AAROM. During an interview and record review on 10/20/2021, at 2:17 PM, RNA 2 stated blank spaces indicated there was no documentation performed. RNA 2 further stated, documentation of refusal or performance of activity should be documented. A review of the facility policy and procedure (P&P) titled, Charting and Documentation, dated 7/2017, indicated the following information was to be documented in the resident medical record including treatments or services performed. The P&P indicated documentation of procedures and treatments will include care-specific details, including date and time procedure/treatment was provided, the name and title of the individual who provided the care, how the resident tolerated the procedure/treatment, whether the resident refused the procedure/treatment, and the signature and title of the individual documenting. c. A review of admission Record indicated Resident 85 was admitted to the facility on [DATE], with diagnoses including Acute Osteomyelitis, (an infection in a bone), left ankle and left foot, Type II diabetes (disease that occurs when your blood glucose, also called blood sugar, is too high) Pressure Ulcer of Sacral (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) Anemia (lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), Peripheral Vascular Disease (a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm), Right below knee amputation (surgical removal of part of the body) and left foot amputation. A review of Resident 85's Order Summary Report, dated 7/31/2021, indicated a physician order for Norco (pain medication) Tablet 5-325 mg, give 1 tablet by mouth every four hours as needed for severe pain (7-10). A review of the Medication Administration Record, dated 7/2021, indicated Resident 85 was given one Norco Tablet 5-325 mg on 7/31/2021. A review of the Controlled II Emergency Drug Supply Log Sheet, not dated, indicated on 7/31/2021 at 10:45 PM one Norco 5-325 mg tablet, was removed from the emergency drug kit. Licensed Vocational Nurse 2 (LVN 2) who removed the Norco 5-325 mg tablet did not fill in her initials on Controlled II Emergency Drug Supply Log Sheet. During an interview on 10/20/2021 at 2:30 PM, the Director of Nursing stated LVN 2 should have completed the nursing Controlled II Emergency Drug Supply Log Sheet when removing a narcotic from the emergency drug supply kit. A review of the facility P&P titled, Administering Medications Policy, dated April 2019, indicated as required or indicated for a medication, the individual administering the mediations records in the resident's medical records: The signature and title of the person administering the drug.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation and interview, the facility failed to provide a safe, sanitary, comfortable, environment for one of three sampled residents (Resident 43). Resident 43 had a soiled toilet which was documented as cleaned every hour. This deficient practice may have resulted in the resident's increased level of discomfort and had the potential to negatively impact the resident's quality of life. Findings: On 10/18/2021 at 9 AM, during the initial tour observation of the facility, inside Resident 43's restroom, the toilet was left soiled. During a concurrent interview, Certified Nursing Assistant 3 (CNA 3) stated and confirmed that the toilet was soiled and that Resident 43 did not use the restroom on his own. On 10/21/2021 at 8:30 AM, during an interview with the housekeeping supervisor, when shown a picture of the soiled toilet, the housekeeping supervisor stated and confirmed the toilet was soiled. The housekeeping supervisor stated when a toilet was soiled a CNA or staff member will inform the housekeeper and the toilet would be cleaned. The housekeeping supervisor stated that a soiled toilet did not provide a homelike environment for the residents. On 10/21/2021 at 10 AM, a review of the Daily Assignment for House Keeping Station 1, for 18 resident rooms, including Resident 43's room, indicated cleaning of restroom every hour. A review of the facility policy titled, Quality of Life- Homelike Environment, dated May 2017, indicated the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: Clean, sanitary and orderly environment.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to observe infection control measures as isolation gowns were disposed of in unlidded disposal bins in resident rooms 41, 43, 45, and 47, and Certified Nursing Assistant 5 (CNA 5) was observed feeding one of 35 sampled residents (Resident 57) in a designated yellow zone room (area in the facility designated for residents that are under observation for COVID-19, a respiratory disease caused by coronavirus) without wearing gloves. These deficient practices had the potential to result in the possible spread of COVID-19 to residents and staff. Findings: a. During an observation on 10/18/2021, at 10:25 AM, resident room [ROOM NUMBER] had signage posted on the door indicating contact precautions (area where gloves and an isolation gown was required before entering), droplet precautions (area where a mask and eye protection was required before entering), and airborne precautions (area where a N95 respirator mask, a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles), is required before entering. An unlidded disposal bin was observed adjacent to the doorway overflowing with isolation gowns and yellow tape was observed at the foot of the doorway. During an observation on 10/18/2021, at 10:26 AM, resident room [ROOM NUMBER] had signage posted on the door indicating contact precautions, droplet precautions, airborne precautions. An unlidded disposal bin was observed adjacent to the doorway overflowing with isolation gowns and yellow tape was observed at the foot of the doorway. During an observation on 10/18/2021, at 10:55 AM, in the hallway between resident room [ROOM NUMBER] and resident room [ROOM NUMBER], a clear drawer containing white isolation gowns and gloves were observed. A sign was observed on top of the drawer indicating yellow zone with arrows pointing left and right. During an observation on 10/18/2021, at 11:09 AM, outside resident room [ROOM NUMBER], with the Infection Preventionist (IP), resident room [ROOM NUMBER] had signage posted on the door indicating contact precautions, droplet precautions, airborne precautions. An unlidded disposal bin was observed adjacent to the doorway overflowing with isolation gowns and yellow tape was observed at the foot of the doorway. During a concurrent interview, the IP stated the disposal bins should be lidded and not overflowing with isolation gowns. b. A review of Resident 57's Facesheet indicated Resident 57 was admitted to the facility on [DATE] with diagnoses including muscle weakness and adult failure to thrive. A review of Resident 57's Minimum Data Set (MDS - a comprehensive standardized assessment and care screening tool), dated 3/4/2021, indicated Resident 57 had severe cognitive impairment, required extensive assistance with feeding, and was on a mechanically altered diet (food with the texture changed to make swallowing easier for residents). During an observation on 10/18/2021, at 12:30 PM, inside resident room [ROOM NUMBER], CNA 5 was observed feeding Resident 57 without gloves. During a concurrent interview, CNA 5 stated she washed her hands before feeding residents but did not wear gloves when feeding residents. CNA 5 further stated she had not received an in-service about glove use while feeding residents. Signage was observed on the door of resident room [ROOM NUMBER] indicating contact, droplet, and airborne precautions. The contact precautions signage indicated gloves should be worn prior to entry. During an interview on 10/20/2021, at 9:22 AM, the IP stated the personal protective equipment required in the yellow zone were gloves, isolation gown, face shield, and N95 respirator mask. The IP further stated gloves were required while providing care in the yellow zone. A review of the facility's document titled, COVID 19 Mitigation Plan, undated, indicated residents in yellow zone will be treated with transmission precautions until a negative test result can be achieved or the resident meets the time criteria to return to the regular room based on current Centers for Disease Control and Prevention (CDC) guidance for the removal of transmission-based precautions. The document further indicated, the IP will oversee the training of all staff for infection prevention and infection control practices, including training of all staff on the donning and doffing procedures required based on the color-coded cohorting groups. A review of the California Department of Public Health (CDPH) document titled, Novel Coronavirus Disease 2019 (COVID-19) Medical Waste Management - Personal Protective Equipment (PPE), dated 11/4/2020, indicated if the facility determines that any PPE should be disposed of into the solid waste, used gloves, facemasks, coveralls, etc. should be placed in a lined container, preferably with a lid/cover.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What safeguards are in place to prevent abuse and neglect?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• 26% annual turnover. Excellent stability, 22 points below California's 48% average. Staff who stay learn residents' needs.

Concerns

• Multiple safety concerns identified: Federal abuse finding, 2 harm violation(s), $101,222 in fines, Payment denial on record. Review inspection reports carefully.
• 48 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
• $101,222 in fines. Extremely high, among the most fined facilities in California. Major compliance failures.
• Grade F (23/100). Below average facility with significant concerns.

Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.

Email me this report

About This Facility

What is Palazzo Post Acute's CMS Rating?

CMS assigns PALAZZO POST ACUTE an overall rating of 3 out of 5 stars, which is considered average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.

How is Palazzo Post Acute Staffed?

CMS rates PALAZZO POST ACUTE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 26%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Palazzo Post Acute?

State health inspectors documented 48 deficiencies at PALAZZO POST ACUTE during 2021 to 2025. These included: 2 that caused actual resident harm and 46 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Palazzo Post Acute?

PALAZZO POST ACUTE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by SERRANO GROUP, a chain that manages multiple nursing homes. With 99 certified beds and approximately 93 residents (about 94% occupancy), it is a smaller facility located in LOS ANGELES, California.

How Does Palazzo Post Acute Compare to Other California Nursing Homes?

Compared to the 100 nursing homes in California, PALAZZO POST ACUTE's overall rating (3 stars) is below the state average of 3.1, staff turnover (26%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Palazzo Post Acute?

Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the substantiated abuse finding on record.

Is Palazzo Post Acute Safe?

Based on CMS inspection data, PALAZZO POST ACUTE has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in California. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Palazzo Post Acute Stick Around?

Staff at PALAZZO POST ACUTE tend to stick around. With a turnover rate of 26%, the facility is 20 percentage points below the California average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 20%, meaning experienced RNs are available to handle complex medical needs.

Was Palazzo Post Acute Ever Fined?

PALAZZO POST ACUTE has been fined $101,222 across 1 penalty action. This is 3.0x the California average of $34,091. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.

Is Palazzo Post Acute on Any Federal Watch List?

PALAZZO POST ACUTE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 99
Avg. Residents: 93
Occupancy: 94.5%
Ownership: For profit - Limited Liability company
Chain: SERRANO GROUP
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
3-Star Rating: +20
Low Turnover: +3
2 Actual Harm citations: -10
48 Deficiencies: -10
Fines ($101,222): -15
Abuse Finding: -15
Final Score: 23/100

Nearby Alternatives

MOUNT SAN ANTONIO GARDENS 5-star MONTECITO HEIGHTS HEALTHCARE &... 5-star MARYCREST MANOR 5-star

View all in LOS ANGELES →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 056456